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LIBRA RY OF CONG RESS. 

Chap*AA_ ^Copyright No. 

Shells. 5/3$ 



UNITED STATES OF AMERICA, 






ESSENTIALS 



OF 



PHYSICAL DIAGNOSIS 



OF THE 



THORAX. 



BY 

ARTHUR M. CORWIN, A.M., M.D., 

Instructor of Physical Diagnosis in Rush Medical College 

Attending Physician to the Central Free Dispensary, 

Department of Rhinology, Laryngology, 

and Diseases of the Chest. 



THIRD EDITION, REVISED AND ENLARGED. 



PHILADELPHIA: 
W. B. SAUNDERS, 

925 Walnut Street. 

1899. 




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tf* 



44223 



Copyright, 1899, 
By W. B. SAUNDERS. 

TWO COPIES RECEIVED, 






•5C0N0 COPY, 






ELECTROTYPED BY 
WESTOOTT & THOMSON, PHILADA. 



PRESS OF 
W, B. SAUNDERS, PHILADA. 



PREFACE TO THE THIRD EDITION. 



In revising the text of the preceding edition and making 
required additions the effort has been, with a few exceptions 
where amplification seemed necessary, to adhere to the orig- 
inal plan of the work as a systematic outline, at once sug- 
gestive as to method and convenient as a condensed state- 
ment of essentials. 

A. M. C. 



PREFACE TO THE SECOND EDITION. 



The first edition of this book, published under the title 
" Outline of Physical Diagnosis of the Thorax," was chiefly 
intended to meet the immediate wants of my classes. From 
its rapid distribution it has seemed to have reached a wider 
field. The present edition under the new title, as published 
by Mr. Saunders, is a revision of the original text, with an 
added section setting forth the signs found in each disease 
of the chest. 

In the preparation of this synopsis I have availed myself 
of the works of the best writers upon Diagnosis, General 
Medicine, Physiology, and Anatomy, from which I have 
endeavored to cull the essentials of the subject in hand. 

To Drs. ¥m, R. Parkes and John Edwin Rhodes I desire 
to express my thanks for their valued services rendered in 
the reading of the proof. 

A. M. C. 



PREFACE TO THE FIRST EDITION. 



The following outline aims to present in systematic form 
the gist of the science of physical diagnosis as applied to the 
thorax. 

In this form it is hoped that the salient points of the sub- 
ject may be the more readily grasped by those who are all 
too busy, while in medical college, to seek them out of ex- 
tensive treatises and to arrange them for proper assimilation. 

It is designed to meet the immediate demands of the 
student, and to be a further guide to a more elaborate study 
of the theme as set forth in existing literature, and as fur- 
nished in the clinical material of public and private practice. 

While the intention has been to confine the subject to the 
thorax, reference has been made to some of the abdominal 
organs, and to various phenomena of the circulatory system 
outside of the chest, where these have seemed to be specially 
related to the chest cavity and its organs. 

I am indebted to Drs. John M. Dodson, James B. Her- 
rick, John Edwin Rhodes, and George H. Weaver for sug- 
gestions in the correction of proof. 

A. M. C. 




Fig. 1.— Corwin's Double Binaural Stethoscope. 




Fig. 2.— Corwin's Multiplex Stethoscope. 







m 



Fig. 3.— Folded Single Stethoscope. 



THE 



PHYSICAL DIAGNOSIS OF THE CHEST. 



THE 

PHYSICAL DIAGNOSIS OF THE CHEST. 



Definition. — Physical Diagnosis is the science and art of 
objective examination of the body as practised upon its 
surface. 

The science of physical diagnosis deals with the character, 
causes, and significance of physical signs, and the methods 
of eliciting them. Signs are objective features, as distin- 
guished from symptoms, which are purely subjective. 

The art of physical diagnosis is the practical applica- 
tion of the science. Its aim is, therefore, to distinguish ob- 
jectively between health and disease, and between various 
diseases. 

Introductory Note. — Objective examination, though deal- 
ing in a broad way with the entire body, finds its most profit- 
able application to the thorax, which is therefore the field of 
its operation as considered in the following synopsis. The 
four divisions of the subject are (1) Topography of the Chest ; 
(2) Landmarks of the Chest ; (3) Methods of Physical Diag- 
nosis ; (4) Physical Signs common in and peculiar to each 
Disease of the Chest. 



17 



18 



PHYSICAL DIAGNOSIS OF THE CHEST. 
TOPOGRAPHY OF THE CHEST. 



The topography of the chest deals with the regions, their 
boundaries and their contents. 







£n 



Fig. 4.— Anterior surface of the chest. 



ANTEKIOK EEGIONS. 



SUPRA-CLAVICULAR regions. 
Boundaries : 

ABOVE, the line drawn from the junction of the ex- 
ternal with the middle third of the clavicle to a point 
at the inner margin of the stern o-mastoid muscle, on 
a level with the upper ring of the trachea, 
BELOW, the superior border of the inner two-thirds 

of the clavicle. 
INTERNALLY, the anterior border of the sterno- 
cleido-mastoid muscle. 
Contents : the apices of the lungs ; parts of the sub- 



TOPOGRAPHY OF THE CHEST 19 

clavian and carotid arteries ; and the subclavian and 
jugular veins, on either side. 

CLAVICULAR regions. 

Boundaries : the margins of the inner two-thirds of the 

clavicle. 
Contents : 

MIGHT SIDE, the apex of the lung. 
EXTERNALLY, the subclavian artery. 
INTERNALLY, the innominate artery and recurrent 
laryngeal nerve. 
LEFT SIDE, the apex of the lung. 

EXTERNALLY, parts of the subclavian vessels. 
INTERNALLY, parts of the subclavian and carotid 
vessels. 

INFRA-CLAVICULAR regions. 
Boundaries : 

ABOVE, the lower border of the clavicle. 

BELOW, the lower border of the third rib. 

INTERNALLY, the border of the sternum. 

EXTERNALLY, a line let fall from the junction of 
the middle with the outer third of the clavicle, and 
passing down an inch to the outer side of the nipple 
(some authorities give the mammillary line). 
Contents : 

EITHER SIDE, lung tissue. 

RIGHT SIDE, a part of the aorta, descending vena 
cava, and right bronchus. 

LEFT SIDE, the pulmonary artery and left bronchus, 
the base of the heart and great vessels. 

MAMMARY regions. 
Boundaries : 

ABOVE, the lower border of the third rib. 
BELOW, the lower border of the sixth rib. 
INTERNALLY, the margin of the sternum. 
EXTERNALLY, a line let fall from the junction of 



20 PHYSICAL DIAGNOSIS OF THE CHEST. 

the middle with the outer third of the clavicle, passing 
an inch to the outer side of the nipple. 
Contents : 

BIGHT SIDE, the lung, right lobe of the liver, right 
auricle, right ventricle, and diaphragm. 

LEFT SIDE, the lung and heart. 

INFRA-MAMMARY regions. 
Boundaries: 

ABOVE, the lower border of the sixth rib. 
BELOW, the lower border of the false ribs and car- 
tilages (the costal arch). 
INTEBNALLY, the costal arch. 

EXTEBNALLY, a line let fall from the junction of 
the middle with the outer third of the clavicle. 
Contents : 

BIGHT SIDE, the lung on deep inspiration, the right 

lobe of the liver. 
LEFT SIDE, the lung and the left lobe of the liver. 

SUPRA-STERNAL region. 
Boundaries : 

ABOVE, a line on a level with the first ring of the 

trachea. 
BELOW, the inter-clavicular notch. 
LATEBALLY, the anterior borders of the sterno- 
cleido-mastoid muscles. 
Contents : the trachea, thyroid gland, vessels, and oesoph- 
agus. 

SUPERIOR STERNAL region. 
Boundaries : 

ABOVE, the inter-clavicular notch. 
BELOW, a line on a level with the third costal car- 
tilages. 
LATEBALLY, the margins of the sternum. 
Contents ; the lung below the level of the second costal 



TOPOGRAPHY OF THE CHEST. 21 

cartilage, the descending vena cava, aorta, pulmonary 
artery, and bifurcation of the trachea. 

INFERIOR-STERNAL region includes the sternum below 
the level of the third costal cartilages. 
Contents : a part of the right auricle and the origins of 
the pulmonary artery and aorta ; a small part of the 
left lung ; a part of the right ventricle, right lung and 
liver, and a part of the attachment of the pericardium 
to the diaphragm. 



LATEKAL KEGIONS. 

AXILLARY regions. 
Boundaries : 

ABOVE, the axilla. 

BELOW, a line on a level with the lower border of the 

mammary region. 
ANTERIORLY, a vertical line let fall from the junc- 
tion of the middle with the outer third of the clavicle. 
POSTERIORLY, the anterior or axillary border of 
the scapula. 
Contents : lung-tissue, and the main bronchi deeply 
placed. 

INFRA-AXILLARY regions. 
Boundaries : 

ABOVE, the axillary region. 
BELOW, the margins of the false ribs. 
ANTERIORLY, the external boundary of the infra- 
mammary region. 
POSTERIORLY, a line let fall from the inferior 
angle of the scapula (scapular line). 
Contents : 

EITHER SIDE, lung-tissue. 

RIGHT SIDE, the right lobe of the liver. 

LEFT SIDE, the spleen and part of the stomach. 



22 



PHYSICAL DIAGNOSIS OF THE CHEST. 







Fig. 5.— Posterior surface of the chest. 



POSTERIOK REGIONS. 
SUPRA-SCAPULAR regions. 

Boundaries, those of the supra-spinous fossae. 
Contents : the apices of the lungs. 

SCAPULAR regions. 

Boundaries, those of the infra-spinous fossae. 
Contents : lung-tissue. 

INTER-SCAPULAR region. 
Boundaries : 

EXTERNALLY, the posterior borders of the scapulae. 
The region extends from the level of the second to 
that of the seventh dorsal vertebra. 
Contents : 

MIGHT SIDE, the lung, bronchial glands, and main 
bronchus. 



LANDMARKS OF THE CHEST. 23 

LEFT SIDE, the lung, glands, main bronchus, aorta, 
thoracic duct, and oesophagus. 

INFRA-SCAPULAR regions. 
Boundaries : 

ABOVE, inter-scapular and scapular regions. 
BELOW, the margins of the false ribs. 
POSTERIORLY, the spines of the dorsal vertebrae, 

below the seventh. 
AJSTEBIOBLY, the scapular line. 
Contents : 

BIGHT SIDE, the liver, lung, and upper end of the 

kidney. 
LEFT SIDE, the lung and a part of the spleen, kid- 
ney, and intestines. 



LANDMARKS OF THE CHEST. 

The landmarks include the various points, lines, and 
measurements to which reference may be made in showing 
the relation of the deep organs to the surface. 

LINES OF REFERENCE. 
VERTICAL lines of reference. 

Meso-sternal line, the mid-line of the sternum. 

Sternal lines, right and left, corresponding to the lateral 
margins of the sternum. 

Mammillary (not mammary) lines, right and left, passing 
vertically through the nipples. 

Para-sternal lines, right and left, passing vertically mid- 
way between the mammillary and sternal lines on the 
respective sides. 

Anterior Axillary lines, right and left, passing vertically 
through the points at w T hich the pectorales majores leave 
the chest, the arms being at right angles to the body. 

Posterior Axillary lines, right and left, passing vertically 



24 PHYSICAL DIAGNOSIS OF THE CHEST. 

through the points at which the latissimus dorsi leave 

the chest, the arms being at right angles to the body. 
Mid-axillary lines, right and left, midway between the 

anterior and posterior axillary lines. 
Scapular lines, right and left, passing vertically through 

the inferior angles of the scapulse. 
Vertebral line, passing through the spines of the vertebrae. 

HORIZONTAL line of reference. 

Horizontal Nipple Line, also the horizontal line passed 
through any costal cartilage. 

OBLIQUE line of reference. 

Linea-costo-articularis, drawn from the left sterno- 
clavicular articulation to the free end of the left 
eleventh rib. 

LANDMAEKS OF THE LUNGS. 

OUTLINE of the lungs. 

Outline of the Right Lung. 

THE ABEX extends an inch and a half above the first 
rib, and is apt to be a little lower than the apex of 
the left lung. 

THE ANTERIOR BORDER lies in the meso-sternal 
line from the level of the second to the level of the 
sixth costal cartilage. 

THE INFERIOR BORDER in adults lies as follows, 
in the average position ; on deep inspiration it is de- 
pressed an inch and a half lower ; in children it is 
from a half to a full interspace higher; in the aged 
it is often as much lower : 
IN THE MAMMILLARY LINE at the sixth rib. 
IN THE MID-AXILLARY LINE at the eighth rib. 
IN THE SCAPULAR LINE at the tenth rib. 
Outline of the Left Lung. 

THE ABEX extends one inch and a half to two inches 
above the first rib. 



LANDMARKS OF THE CHEST. 25 

THE ANTERIOR BORDER lies in the meso-sternal 

line from the level of the second to the level of the 

fourth costal cartilage. 
THE INFERIOR BORDER lies (in the average 
position), 

IN THE MESO-STERNAL LINE, at the fourth costal 
cartilage. 

IN THE PARA-STERNAL LINE, at the fifth rib. 

IN THE MAMMILLARY LINE, at the sixth rib. 

IN THE MID- AXILLARY LINE, at the eighth rib. 

IN THE SCAPULAR LINE, at the tenth rib. 
The inferior border of the left lung reaches half to 

three-quarters of an inch lower than the right in the 

mid-axillary and scapular lines. 

FISSURES of the lungs. 

Fissures of the Right Lung. 
THE LONG FISSURE. 

ITS POSITION : it separates the lower from the mid- 
dle and upper lobes. 
ITS DIRECTION is from above and behind, obliquely 

downward and forward. 
ITS RELATION to the chest is about as follows : 
Near the Vertebral Column it is three inches 
below the apex of the lung (near the inner end 
of the spine of the scapula). 
In the Mid-axillary Line it is about the level of 

the fourth rib. 
Just within the Mammillary Line it cuts the 
lower margin of the lung at the sixth rib. 
THE SHORT OR LESSER FISSURE. 

ITS POSITION : it separates the upper from the mid- 
dle lobe. 
ITS DIRECTION is obliquely downward and forward 
from a point near the anterior border of the scapula, 
where it joins the long fissure. 



26 PHYSICAL DIAGNOSIS OF THE CHEST. 

ITS RELATION to the chest-wall is about as follows : 
It lies at first nearly under the third rib, but crosses 
the third intercostal space about the mammillary 
line, and cuts the anterior border of the lung about 
the junction of the fourth costal cartilage with the 
sternum. 
Fissure of the Left Lung, 

THE LONG FISS JIBE (the left lung has but one fissure). 
ITS POSITION : it separates the upper from the lower 

lobe. 
ITS DIRECTION is from above and behind, obliquely 

downward and forward. 
ITS RELATION to the chest-wall is as follows (in the 
average position) : 
Near the Vertebral Column it is about three 

inches below the apex of the lung. 
In the Mid-axillary Line it is about the level of 

the fourth rib. 
In the Mammillary Line it cuts the lower mar- 
gin of the lung at the sixth rib. 

LOBES of the lungs. 
Anteriorly : 

ON THE BIGHT SIDE, 

THE UPPER LOBE lies above the third intercostal 

space. 
THE MIDDLE LOBE lies below the third interspace, 

reaching to the lower margin of the lung. 
THE LOWER LOBE is practically absent anteriorly. 
ON THE LEFT SIDE, 

THE UPPER LOBE reaches from the apex to the 

lower margin of the lung. 
THE LOWER LOBE is practically absent anteriorly. 
Laterally : 

ON THE BIGHT SIDE, 

THE MIDDLE LOBE is present above the fourth rib. 



LANDMARKS OF THE CHEST. 



27 



THE LOWER LOBE reaches from the fourth rib to 
the lower margin of the lung. 
ON THE LEFT SIDE, 

THE UPPER LOBE lies above the fourth rib, 
THE LOWER LOBE reaches from the fourth rib to 
the lower margin of the lung. 
Posteriorly : 

ON BOTH SIDES, 
THE UPPER LOBE practically lies above the spine 

of the scapula. 
THE LOWER LOBE reaches from the spine of the 
scapula to the lower margin of the lung. 

THE TRACHEA. 
Dimensions. 

LENGTH, four and one-half inches. 
CALIBME, three-fourths to one inch. 




Median Line 



Fig. 6.— Showing divergence of main bronchi. 

Bifurcation, under the middle of the sternum about the 
level of the second costal cartilage, at the level of the 
third dorsal vertebra. The septum or line of divergence 
between the two bronchi is to the left of the median 
line, thus influencing the direction of foreign bodies 
which enter the trachea. 



28 



PHYSICAL DIAGNOSIS OF THE CHEST. 



THE PRIMARY BRONCHI. 
Direction. 

THE MIGHT bronchus is nearly horizontal. 

THE LEFT bronchus is oblique. 
Position. 

THE BIGHT lies under the second rib. 

THE LEFT lies under the second intercostal space. 
Length. 

THE RIGHT is about one inch long. 

THE LEFT is nearly two inches long. 
Calibre. 




Fig. 7.— Relations of the heart (Holden). 

THE BIGHT bronchus is larger than the left, and 
its main branch leading to the upper lobe is given 
off near the origin of the right main bronchus, " fully 
two inches and a half above the corresponding left 
bronchial tube " (Carey). This bronchial branch may 
even spring directly from the trachea. 



LANDMARKS OF THE CHEST. 29 

LANDMAEKS OF THE HEART. 
OUTLINE of the heart. 

The Base nearly corresponds in level with the superior 
margin of the third rib. 

The Apex lies under the fifth intercostal space, 

TWO INCHES BELOW the nipple (in the male) and 
HALF AN INCH TO THE BIGHT of the left mam- 
millary line. 

The Right Margin corresponds with a line beginning on 
the third costal cartilage half an inch to the right of 
the right sternal line, curving slightly to the right and 
downward to the end of the sternum. 

The Left Margin corresponds with a line beginning on 
the third costal cartilage an inch to the left of the left 
sternal line, curving to the left and downward to the 
apex beat, but not including the nipple. 

The Lower Margin corresponds nearly with a line join- 
ing the apex and the end of the sternum. 

RELATION of the heart to the lung in front. 

It is Covered by the lung (cardiac dulness) from the 
upper margin of the third to the lower margin of the 
fourth rib, and below the fourth rib between the para- 
sternal line and the left margin of the heart. 

It is Uncovered by the lung (cardiac flatness) in the tri- 
angular or irregularly quadrilateral area bounded on 
the right by the meso-sternal line, on the left and above 
by a line drawn from the fourth costal cartilage to a 
point a little to the right of the apex beat. (See 
"Cardiac Dulness/' p. 176.) 

VALVES of the heart. 
Position (Gray). 

SEMILUNAR VALVES. 

THE PULMONIC valve lies behind the left sternal 
line at .the level of the third costal cartilage. 



30 PHYSICAL DIAGNOSIS OF THE CHEST. 

THE AORTIC valve lies close to the left sternal line, 
behind the third intercostal space. 
A URICULO- VENTRICULAR VAL VES. 

THE TRICUSPID valve lies behind the meso-sternal 
line about the level of the fourth costal cartilage. 

THE BICUSPID or mitral valve lies about one inch 
to the left of the sternum behind the third inter- 
costal space. 

LANDMAEKS OF THE AOETA. 

The aorta is most superficial in the right second intercostal 
space at the edge of the sternum. The arch of the aorta 
lies an inch below the inter-clavicular notch. 

LANDMAEKS OF THE INNOMINATE AETEEY. 

Its course may be traced by an oblique line drawn from 
the mid-sternal line at the level of the second costal cartilage 
to the right sterno-clavicular articulation. 

LANDMAEKS OF THE LIVEE. 

RIGHT LOBE of the liver. 
Its Upper Margin lies, 

IN THE MAMMILLARY LINE, at the fourth in- 
tercostal space. 
IN THE MID-AXILLARY LINE, at the sixth rib. 
IN THE SCAPULAR LINE, at the eighth rib. 
Its Lower Margin lies half an inch below the costal arch, 

in the average healthy adult male. 
Relation of the liver to the lung. 

IT IS COVERED by lung (hepatic dulness), 

IN THE MAMMILLARY LINE, from the fourth inter- 
space to the sixth rib. 
IN THE MID-AXILLARY LINE, from the sixth to the 

eighth rib. 
IN THE SCAPULAR LINE, from the eighth to the 



LANDMARKS OF THE CHEST. 31 

tenth rib (the lower margin of the lung may be 
depressed an inch and a half on deep inspiration). 
IT IS UNCOVERED by lung (hepatic flatness) from 
these points (sixth, eighth, and tenth ribs) down- 
ward. 

LEFT LOBE of the liver. 

Its Upper Margin lies under and against the diaphragm, 
adjoining the heart. 

Its Lower Margin (in the median line) lies about mid- 
way between the end of the appendix sterni and the 
umbilicus. 

Its Left Margin reaches nearly to the left mammillary 
line. 

LANDMAKKS OF THE SPLEEN. 
THE SPLEEN IS COMPLETELY SHELTERED beneath 
the ribs, and cannot be felt in health except in rare cases. 
Its Position and Size are determined by percussion, 
which should be lightly performed. 

THE OUTLINE of the spleen. 

Its Upper Margin lies under the ninth rib. 

Its Lower Margin lies under the eleventh rib. 

Its Anterior Extremity nearly reaches the linea costo- 

articularis, drawn from the free end of the eleventh rib 

to the left sterno-clavicular articulation. 
Its Posterior Extremity approaches within two-thirds 

of an inch of the body of the tenth dorsal vertebra. 

THE DIRECTION is obliquely backward and upward, the 
long axis corresponding nearly with the direction of the 
tenth rib. 

THE RELATION of the spleen to the lung. 

It is Covered by lung in its posterior and upper third, 
which lies in the infra-scapular region. 

It is Uncovered by lung in its anterior and lower two- 
thirds, which lie chiefly in the infra-axillary region. 



32 PHYSICAL DIAGNOSIS OF THE CHEST. 

Its Anterior Inferior Margin is easily defined upon 
gentle percussion by the contrast of its dulness com- 
pared with the tympanitic note of Traube's space, which 
the spleen bounds posteriorly. (See page 76.) 

LANDMAEKS OF THE VEETEBE.E. 

THE SEVENTH CERVICAL VERTEBRA, vertebra 
prominens, is readily made out. 

THE TWELFTH DORSAL VERTEBRA may be located 
by reference to the twelfth rib, which may be felt when 
the lumbar muscles are relaxed ; in muscular subjects it 
may be located by following the lower margin of the 
trapezius muscle. 

ALL THE SPINES are located by slight friction with the 
finger, reddening the skin over their tips. 

SLIGHT CURVATURE of the vertebral column to the 
right or left exists in right- or left-handed persons. 

LANDMAEKS OF THE EIBS. 

THE SECOND RIB is on a level with the prominence {angle 
of Lewis), more or less marked in all persons, at the junc- 
tion of the first and second pieces of the sternum. 

THE SEVENTH RIB lies at the inferior angle of the scap- 
ula when the arms hang at the sides. 

THE FIFTH RIB is just covered by the convex lower bor- 
der of the pectoral is major. 

THE THIRD COSTO-STERNAL JUNCTION is on a 

level with the body of the sixth dorsal vertebra. 

THE HORIZONTAL NIPPLE LINE cuts the sixth inter- 
costal spaces in the mid-axillary lines. 

THE ELEVENTH AND TWELFTH RIBS can always be 
felt when the abdominal wall is relaxed. 



METHODS OF PHYSICAL DIAGNOSIS. 33 

THE INFERIOR END OF THE STERNUM is on a level 
with the tenth dorsal vertebra. 



LANDMAKKS OF THE SCAPULA. 

The scapula lies over the ribs from the second to the 
seventh. The inner end of the spine of the scapula is 
nearly on a level with the third dorsal vertebra, main 
bronchus, and beginning of the pulmonary fissures behind. 



METHODS OF PHYSICAL DIAGNOSIS. 

The methods of physical examination are inspection, pal- 
pation, mensuration, percussion, auscultation, and succussion. 

INSPECTION. 
Inspection reveals color, nutrition, size, form, posture, and 
movements. 

COLOR may be due to pigmentation, or vascularization, or 
both. 
Color dependent upon pigmentation may be 
NORMAL. 

LOCAL, as in the areolae about the nipples, color of 

the eyes and hair. 
GENERAL, as in the Negro, Malayan, Indian, bru- 
nette, and blonde. 
ABNORMAL. 

LOCAL, moles, lentigo, chloasma, the seat of scars, 

leucoderma. 
GENERAL, icterus, argyria, Addison's disease. 
Color dependent upon vascularization. 

NORMAL, erythema, ruddy complexion or the opposite. 
ABNORMAL. 
LOCAL. 

Arterial, congestion, eruptions, etc. 



34 



PHYSICAL DIAGNOSIS OF THE CHEST. 



Venous, ecchymosis, enlarged superficial veins and 
capillaries. 
GENERAL. 

Arterial, congestion, or its opposite, pallor, chloro- 



sis, anaemia. 



Venous, cyanosis, morbus cseruleus. 
Color dependent upon both vascularization and pigmenta- 
tion is observed in various cachexia, malignant disease, 
disease of the liver, etc. 

NUTRITION is manifested by the degree of fatty deposits 

or muscular development, as well as by the color. 
SIZE of the chest. 

Normal size of the chest. 

CIRCUMFERENCE of the chest at the level of the 
nipples in man, just above the mammae in women. 
AVERAGE circumference thirty-four inches in men, 

thirty-two in women. 
USUAL EXTREM ES, twenty-eight to forty-four inches. 
Chest-measurement as related to Height and Weight. 



Height. 


Chest. 


Standard 


20 per cent. 


45 per cent. 






Weight. 


under weight. 


over weight. 


5 feet 


m 


115 


92 


167 


5 " 1 in. 






34 


120 


96 


174 


5 " 2 " 






35 


125 


100 


181} 


5 " 3 " 






36 


130 


104 


188} 


5 " 4 " 






36} 


135 


108 


195 


5 " 5 " 






37 


140 


.112 


203 


5 " 6 " 






37} 


143 


114 


207 


5*7." 






38 


145 


116 


210 


5 " 8 " 






38} 


148 . 


119} 


215 


5 " 9 " 






39 


155 


124 


224} 


5 " 10 " 






39| 


160 


128 


232 


5 " 11 " 






m 


165 


132 


239 


6 " . . 






41 


170 


136 


246 



RESPIRATORY EXPANSION, two to seven inches. 
Average in Women, two inches and a half. 
Average in 'Men, three inches and a half. 
Usual Extremes, two to four inches. 



METHODS OF PHYSICAL DIAGNOSIS. 35 

SEMI-CIRCUMFERENCE laterally. 

THE RIGHT SIDE is usually half an inch larger than 
the left in right-handed persons. 
Abnormal size in 

CIRCUMFERENCE ; this may be disproportionately 
SMALL compared with the vertical diameter of the 
chest, when it is generally associated with flatness 
or hollowness of the upper anterior part of the 
chest, wing-like projection of the scapulae, an acute 
costal angle, and deficient respiratory expansion. 
The circumference is apt to be disproportionately 
LARGE in marked emphysema. 
SEMI-CIRCUMFERENCE; either side of the chest 
may be 
SMALL compared with the other, as a result of fibroid 
contractions of the lung on that side, following 
pleurisy, pneumonia or collapse. It may be 
LARGE as compared with the other, in case of exten- 
sive pleuritic effusion or pneumothorax. 
FORM of the chest, 

Normally the chest is a nearly symmetrical, truncated, 
conical pyramid, flattened slightly in its antero-posterior 
diameter. 
Abnormal forms of the chest. 
ASYMMETRICAL forms. 

LOCAL BULGINGS may be due to irregularities of the 
Chest-tvali ; tumors or swellings such as sarcoma, 
abscess, periostitis, or deformities of the bony 
framework. 
Pressure from ivithin, due to the 
Thoracic Organs. 
Circulatory organs. 

Enlargement of the heart in children. 
Hydro- or pneumo-pericardium, aneurysm. 
Lungs and Mediastinum. 
Tumors or swellings. 



36 PHYSICAL DIAGNOSIS OF THE CHEST. 

Pleuritic accumulation of gas, fluid, or solids, 
e. g. pneumothorax, serothorax, tumors. 
Abdominal Organs. 

Enlargement of abdominal organs. 
Abnormal accumulation of gas, fluid, or solids, 
encroaching upon the thorax. 
LOCAL DEPRESSIONS, as the retraction of the supra- 
and infra-clavicular regions from contraction of the 
apex of the lungs in phthisis ; or the retraction of 
the chest in any region following fibroid induration 
of the lung. 

Depression of the Precordial Space is rare. It 
may be the result of pleuro-pericarditis with ad- 
hesion of the visceral and parietal layers. 
Apparent Depressions of the Chest may be due 
to local muscular wasting. 
RELATIVELY SYMMETRICAL forms of the ab- 
normal chest. 
THE PIGEON BREAST deformity of the chest occurs 
chiefly in childhood, and is characterized by lateral 
constriction of the thorax, with straightening of 
the true ribs and prominence of the lower end of 
the sternum ; this is a result of rhachitis. 
THE RHACHITIC CHEST is developed in early life; it 
is characterized by lateral retraction of the thoracic 
walls, the anterior surface being broader than in 
the pigeon breast, and the sternum less prominent ; 
the costo-chondral junctions are thickened, pre- 
senting a series of bead-like eminences known as 
the rhachitie rosary. 
THE ALAR OR FLAT CHEST is characterized by 
wing-like projections of the scapulae, usually asso- 
ciated with a narrow chest, sloping shoulders, and 
an acute costal angle. It is commonly significant 
of constitutional weakness, which favors the devel- 
opment of pulmonary phthisis. 



METHODS OF PHYSICAL DIAGNOSIS. 37 

THE EMPHYSEMATOUS OR BARREL-SHAPED 
CHEST is characterized by roundness of contour, 
the antero-posterior diameter being lengthened, the 
transverse diameter shortened, and the upper end 
of the sternum prominent ; the intercostal spaces 
are wide and full, the shoulders are thrown for- 
ward, the scapulae separated, and the whole pos- 
ture stooping. 

FUNNEL BREAST, characterized by sinking in of the 
lower end of the sternum, is a congenital deformity 
sometimes observed in several branches of the same 
family ; it may be so marked as to interfere seriously 
with respiration. Shoemakers' breast is an acquired 
deformity of similar form, and is caused by the 
pressure of tools against the lower part of the 
sternum. 

HARRISON'S GROOVE is a horizontal line of depres- 
sion along the false ribs, corresponding to the in- 
sertion of the diaphragm ; it is sometimes observed 
in conditions of chronic inspiratory dyspnoea neces- 
sitating powerful action of the diaphragm, especially 
in rhachitic children. 

SPINAL CURVATURES ; the chest may be asymmet- 
rical or symmetrical, deviations being either antero- 
posterior or lateral, or both. These may be due 
either to defective development of the bodies of the 
vertebrae or to caries. 

POSTURE. The position of the body as a whole or in its 
parts is significant as an aid to diagnosis. 
Voluntary posture, as ordered by the examiner. 
X A TUBAL postures. 

FIXED position, upright, standing, sitting, recumbent. 
CHANGE from the upright posture to recumbency 
may reveal movable organs, fluids or gases, or 
evidence of pain. 



38 PHYSICAL DIAGNOSIS OF THE CHEST. 

UNNATJJBAL or specially-arranged postures to facil- 
itate examinations — germ-pectoral, left lateral semi- 
prone, etc. 
Involuntary posture, as assumed by the patient as a re- 
sult of disease or habit, or to relieve pain or dyspnoea. 
BOS TUBE OF THE BODY AS A WHOLE. 

DROOPING, relaxed, or reclining posture as indicat- 
ing lassitude, debility, helplessness, paralysis. 
FORWARD, BACKWARD, OR LATERAL inclination 
more or less fixed, as a result of 
Prolonged Habit, or from occupation. 
Partial Destruction of the Bony Support (Pott's 

disease, etc.). 
Muscular Contraction from 

Inflammation of the soft parts, pain, and 
Abnormal Pressures from tumors or enlarged 
organs — viz. forward inclination to relieve the 
backward pressure of an aneurysm or other 
tumor against the trachea, marked flexion of 
the body in peritonitis, colic, etc. 
Lesions of the Central or Peripheral 
Nervous System may produce opisthotonos, 
or over-extension of the vertebral column, 
from tonic contraction of the posterior, cer- 
* vical, dorsal, and lumbar muscles, with asso- 
ciated extension of the thighs and extension 
of the legs in tetanus, spinal meningitis, hys- 
teroid convulsions. 
Atrophy. 
RECUMBENCY UPON OR INCLINATION TOWARD 
THE AFFECTED SIDE is common in the first stage 
of pleurisy, and is usual in the stage of effusion, 
especially if this is considerable in amount. 
INABILITY TO LIE ON THE AFFECTED SIDE in 
case of superficial inflammations, or in some cases 
of cardiac disease. 



METHODS OF PHYSICAL DIAGNOSIS. 39 

INABILITY TO LIE DOWN AT ALL in certain cardiac 
and pulmonary diseases interfering with respira- 
tion — viz. asthma, marked emphysema, pulmonary 
oedema, double effusion, and hi cases of abdomiual 
tumor or ascites making marked pressure upon 
the diaphragm. 
CONSTANT RECUMBENCY UPON THE BACK is 
the rule in grave disorders. Ability to turn upon 
the side is therefore a good sign. 
JPOSTUBJE OF THE BODY IN ITS JPABTS. 
FIXED POSITION of the limbs in any position in 

catalepsy. 
LIMBS RELAXED or parts of the body drawn to the 

opposite side in unilateral paralysis. 
LIMBS OR HEAD DRAWN INTO DISTORTED POSI- 
TIONS by muscular or fibroid contractions. 
POSITION OF A LIMB involuntarily corresponds 
to that giving least pain in disease of the 
joints. 
FACIAL EXPRESSION is closely related to posture, 
and depends largely upon the influence of the in- 
tellect, feeling, and will. 

Intellectual, expression of intelligence or imbe- 
cility, etc. 
Emotional, expression of pain, anxiety, fear, grief, 

anger, joy, etc. 
Volitional. 
Voluntary control in the change of expression. 
Involuntary distortion of features as seen in pa- 
ralysis and contraction, or swelling or tumors. 
(Edema of the face suggests kidney trouble. 

MOVEMENTS. 

General muscular movements are of interest as being 
normally or abnormally present or absent, as in paralysis 
and chorea, or as eliciting pain. 



40 PHYSICAL DIAGNOSIS OF THE CHEST. 

GAIT is peculiar in various diseases of the central or 
peripheral organs. 

CONVULSIONS OU TREMORS may be present. 

COUGHING, SNEEZING, SNORING, SIGHING, 
YA WNING, AND HICCO UGH, while visible signs 
as well as symptoms often of disease, are better classed 
with subjective features. Cough as a sign is referred 
to under Auscultation. 
Respiratory movements. 

NORMAL breathing is termed eupncea. The two sides 
of the chest should expand equally, and the upper 
part of the chest should be well filled out with each 
inspiration. There is a slight falling in of the inter- 
costal spaces during inspiration, and a corresponding 
shallowness of these during expiration. 

In certain thin persons when recumbent, with the light falling aslant 
the costal interspaces, a shadowy line obliquely crossing these may 
be seen to move up and down, corresponding to the lower margin 
of the lung in expansion and retraction. It is of little significance. 
(See Vierordt, fourth Am. edition, page 74.) 

THE RHYTHM or ratio of the inspiratory to the ex- 
piratory act is as six to seven (Gibson), there being 
no pause between them. 

THE TYPES of respiration include costal or superior 
costal breathing as observed in women, inferior 
costal breathing as usually observed in men, ab- 
dominal or diaphragmatic breathing as seen in 
children. 

If superior costal breathing is diminished or absent in women, there 
is suspicion of some pulmonary disorder — tuberculosis, pleurisy 
with effusion or adhesions. If the movement of the diaphragm is 
impaired, as by ascites, peritonitis, abdominal tumor, enlarged liver 
or spleen, or excessive flatulence, abdominal and inferior costal 
breathing will be limited. 

THE RAPIDITY of normal respiration varies accord- 
ing to 





44 


per 


minute, 


years 


26 


a 


u 


a 


20 


a 


u 


ve" 


18 


a 


it 


7 " 


16 


u 


a 


U 


18 


a 


a 



METHODS OF PHYSICAL DIAGNOSIS. 41 

Intrinsic Conditions* 

Age. 

Under one year, 
One to five 
Five to twenty 
Twenty to twenty-five 
Twenty-five to thirty 
Thirty to fifty 
Physical 

State, posture. 

Activity, general muscular, digestion, etc. 
Mental 

State, posture. It is more rapid in the up- 
right posture than in recumbency or the 
sitting position. 
Activity, emotional, volitional. 
Extrinsic Conditions. 

Rarity of the Atmosphere, elevation, etc. 
Excessive Heat acting on body-temperature. 
ABNORMAL breathing regards the 
FORM of the chest during respiration. 

Expansion of the chest in abnormal breathing. 
Diminished expansion may be unilateral or bi- 
lateral, and it is found in conditions of 
faulty development, tuberculosis of the lungs, 
fibrosis, pneumonia, and other causes of con- 
solidation, and pleuritic adhesions. Expan- 
sion as well as expiration is limited in em- 
physema. 
Bulging- of the intercostal spaces during expira- 
tion is observed in emphysema. 
Retraction of the soft parts of the chest, xiphoid 
process, and false ribs in inspiration occurs in 
croup, paralysis of the vocal cords, and other 
conditions involving obstruction of the upper 
air-passages. 



42 PHYSICAL DIAGNOSIS OF THE CHEST. 

RAPIDITY OF ABNORMAL RESPIRATION. 

Abnormally Rapid respiration is termed hy- 
perpncea. This is observed in most conditions 
causing dyspnoea (vide), notably in the following : 
In Fever, especially in nervous persons, and in 

children. 

In all Conditions Causing" Painful Breathing-, 

such as diseases of the pleura, diaphragm, and 

peritoneum, fracture of the ribs, pleurodynia. 

In Diseases Narrowing* the Bronchial Tubes : 

asthma, bronchitis. 
In Conditions Lessening the Aerating and Cir- 
culatory Areas of the Lungs. 
Pulmonary Disease : emphysema, oedema, 

pneumonia, etc. 
Pleuritic Affections : air, fluids, or solid 
tumors in the pleural cavity pressing on the 
lungs. 
Abdominal Affections : tumors, swellings, 
or effusion, or gas. 
In Disease of the Heart affecting the pulmonary 

circuit. 
In some Diseases of the Nervous System, 
e. g. hysteria, apoplexy, and sometimes from 
the irritating effects of poisons upon the nerve 
centres. 
Abnormally Slow Respiration might well be 
termed hypopnoea. This is observed in the 
course of Cheyne-Stokes respiration, and some- 
times in diseases of the brain and meninges ; in 
acute infectious diseases with marked mental 
dulness ; in stenosis of the upper air-passages, 
due to intra-tracheal tumors, foreign bodies, in- 
flammation, compressions from without, and 
paralysis of the abductors of the vocal cords ; 
in some cases of poisoning, as from opium, 



METHODS OF PHYSICAL DIAGNOSIS. 43 

chloral, aconite, chloroform, etc., and in ursemia 
and diabetes, etc. 
Suspended Respiration is termed ajmoea, which is 
due to want of a proper stimulus to respiration, 
ow T ing to saturation of the blood with oxygen 
and the presence of a deficient amount of car- 
bonic-acid gas ; it is observed in the course of 
Cheyne-Stokes respiration. It seems to be the 
condition of the foetus in utero. 
Asphyocia literally means absence of the pulse — 
i. e. the almost pulseless condition of suspended 
vitality resulting from lack of oxygen in the 
blood or its saturation with C0 2 . The stages of 
asphyxia (Landois) are 
Hyperpncea, lasting about one minute. 
Convulsions, lasting about one minute. 
Exhaustion, lasting about three minutes, during 
which the heart continues to beat, but feebly. 
When the heart ceases to beat recovery is im- 
possible. 
VARIATION IN THE RHYTHM OF RESPIRATION. 
An increase in the number or depth of respirations, 
or both, is the chief characteristic of dyspnoea or 
difficult breathing. 
Dyspnoea, 

Varieties of Dyspnoea. 

Inspiratory dyspnoea : dyspnoea may be 
purely inspiratory, or it may be associated 
with difficult expiration in varying degree ; 
it is the result of obstruction to the ingress 
of air into the lung, and is observed in 
croup, compression of the trachea, and 
paralysis of the diaphragm, etc. 
Expiratory dyspnoea, pure, or associated 
with difficult inspiration, is due to obstruc- 
tion to the exit of air from the lung, as is 



44 PHYSICAL DIAGNOSIS OF THE CHEST. 

typically observed in asthma and emphy- 
sema. 

Mixed expiratory and inspiratory dyspnoea is 
most frequent ; it is observed in many dis- 
eases of the lungs and heart, and in fever. 

Exaggerated dyspnoea, or orthopnoea, re- 
quiring the sitting or standing posture and 
the use of the extra muscles of respiration. 
It is always due to bilateral interference 
with breathing, and therefore may be pres- 
ent in severe croup, bronchitis, asthma, 
emphysema, and cardiac disease, and is 
wanting in unilateral affections, such as 
pneumonia, pleurisy, phthisis, etc. In 
cardiac dyspnoea the movement of the ribs 
is natural, like that in a person out of 
breath from running. In respiratory dysp- 
noea, on the other hand, there is local or 
general disturbance of the lateral and 
antero-posterior movement of the ribs, with 
an increase in the vertical or diaphragmatic 
(W. H. Thomson). 

Che yne -Stokes Respiration is character- 
ized by a number of shallow respirations 
which become deeper and more dyspnoeic to 
a given point at which there may be a groan, 
and then grow r more superficial till they ap- 
parently cease ; after a pause (apnoea) the 
series is repeated, the whole cycle occupying 
from thirty-five seconds to a minute, the 
number of respirations usually being about 
thirty. During the pause the pupils are 
contracted and immobile to light, and con- 
sciousness is usually lost. In some cases 
consciousness returns with deep breathing, 
and the pupils dilate and react to light. 



METHODS OF PHYSICAL DIAGNOSIS. 45 

This is normal in animals during hiberna- 
tion ; abnormal in man, due to cerebral or 
medullary disease (meningitis, hemorrhage, 
tumors), uraemia, certain affections of the 
heart, and to opium-poisoning. 
Causes of Dyspnoea. 

Eespieatory causes of Dyspncea may de- 
pend upon 
Insufficient quantity of air supplied to the 
lungs, owing to — 

1. Imperfect respiratory movements, due 

to— 
(a) Paralysis, lesions of the central or 

peripheral nervous system. 
(6) Pain, as in inflammation of the 

pleura and peritoneum, pleurodynia, 

intercostal neuralgia, trichinosis of 

the diaphragm, etc. 

(c) Muscular weakness. 

(d) Yielding walls of the chest due to 
rickets and fractures. 

(e) Loss of elasticity of the chest- wall : 
myositis ossificans, scleroderma. 

2. Loss of elasticity of the lungs from 

emphysema, pleuritic adhesion, pro- 
longed compression. 

3. Lessened capacity of the chest, due 

to— 

(a) Bony malformations. 

(6) Pressure from thoracic or abdom- 
inal effusion or tumors. 

4. Lessened lumen of the air-passages : 
(a) Extra-mural causes : cicatricial con- 
tractions, pressure of tumors, etc. 

(6) Intra-mural causes : thickening of 
the walls of the air-passages, mus- 



46 PHYSICAL DIAGNOSIS OF THE CHEST. 

cular spasm, as in bronchitis, asthma, 
and laryngismus stridulus. 

(c) Inter-mural : foreign bodies, secre- 
tions, and false membranes within 
the air-passages. 
5. Diminished surface for circulation and 
interchange of gases in the lung, 
owing to — 

(a) Inflammation of the lungs : pneu- 
monia, fibrosis, tuberculosis. 

(6) Collapse or compression of the lung 
from pressure of air, fluid, or solids : 
tumors, pleuritic effusion, pneumo- 
thorax. 

(c) Destruction of the alveolar capil- 
lary network, as in emphysema. 
Modified quality of the oAr which is inhaled. 

1. Insufficient density due to heat, high 
altitude, decreased atmospheric pres- 
sure. 

2. Deleterious adulterations : noxious 
gases, etc. 

3. Insufficient oxygen. 
Circulatory causes of Dyspncea include 

Diminished quantity of blood abated, owing 
to— 

1. Oligsemia, after acute hemorrhage. 

2. Pulmonary ischemia, from 
(a) Vis a fronte, due to 

Pulmonary disease : emphysema, 

fibrosis, compression, etc. 
Arterial disease. 

Extra-mural : compression, liga- 
tion. 
Intra-mural : inflammation of the 
arterial coats. 



METHODS OF PHYSICAL DIAGNOSIS. 47 

Inter-mural : embolism. 
(b) Vis a tergo may be diminished 
owing to 
Cardiac inefficiency from 
Valvular disease. 
Compression of the heart by peri- 
cardiac or pleuritic effusion. 
Muscular weakness of the heart 
from atrophy, myocarditis, de- 
generation, etc. 
Modified quality of the blood. 

1. Super-heated blood acts on the re- 
spiratory centre, heat-dyspnoea. 

2. Deteriorated blood : pernicious anae- 
mia, fevers, poisons. 

Circulatory Movements. 

VASCULAR MOVEMENTS. 
VENOUS movements (pulsations). 
Normal Venous Movements. 

Swelling* of the Jugulars, upon prolonged 
forced expiration with closed glottis, is visible. 
Jugular Presystolic pulsation (slight) is rarely 
visible in health (Vierordt). 
Abnormal Venous Movements. 

Jugular Systolic pulsation occurs in tricuspid 
regurgitation, usually from dilatation of the 
right ventricle. It is not visible until the 
backward pressure in the veins has rendered 
incompetent the valves at the root of the 
jugular vein, which often does not occur until 
some time after tricuspid insufficiency has been 
established. It is best brought out by com- 
pressing the vein halfway up the neck, which 
allows the wave from the right ventricle to 
fill the empty vessel. When venous pulsa- 
tion is present in the jugular it may be felt 



48 PHYSICAL DIAGNOSIS OF THE CHEST. 

sometimes in the liver, though it may be ab- 
sent from the jugular and present in the liver. 
It may be absent in the upright posture and 
present in recumbency. The latter position 
always accentuates it owing to gravity. This 
also is the case if the patient in recumbency 
be inclined with the head lower than the feet. 
Slight undulation of the veins may sometimes 
be propagated from the arteries in normal 
persons. 
Hepatic venous systolic pulsation is sometimes 
visible in marked tricuspid regurgitation. 
ARTERIAL movements (pulsation). 
Normal Arterial Movements. 

Carotid pulsation is frequently visible under the 
angle of the jaw, varying with the degree of 
adiposity and the force and excitation of the 
heart. 
Aortic pulsation is exceptionally visible in the 
supra-sternal region (high position of the 
arch). 
Abnormal Arterial Pulsation. 

Carotid pulsation, when marked, may signify 
hypertrophy of the left ventricle, insufficiency 
of the aortic valve, arterial sclerosis (aortic), 
or aneurysm. 
Aortic pulsation 

In the neck is sometimes due to insufficiency 
of the aortic valve, to aneurysm, or to hy- 
pertrophy of the left ventricle. 
In the bight second intercostal space 
pulsation is always abnormal, and is usually 
significant of one of the conditions just 
mentioned. 
Pulmonary arterial pulsation appears to the left 
of the sternum in aneurysm of this artery. 



METHODS OF PHYSICAL DIAGNOSIS. 49 

Pulsation of this artery may sometimes be 
seen in fibrosis of the lung. 
Capillary pulsation (Quincke) may be seen 
slightly in 

Marked hypertrophy of the left ven- 
tricle, and in some conditions of low ar- 
terial tension ; it is most characteristic in 
Aortic insufficiency, of which it may be 
considered diagnostic when well marked. 
It is occasionally observed in cases of exag- 
gerated ophthalmic goitre (Osier). The 
pulsation is observed in the bed of the 
finger-nails, at the fundus of the eye, in 
the mucous membrane of the lip under 
pressure of a glass slide, and also in the 
line of erythema caused by drawing the 
finger-nail with some force over the patient's 
skin. This pulsation may very rarely ex- 
tend through into the small veins. 
CARDIAC MOVEMENT (pulsation). 
APEX BEAT of the heart. 

Cause of the apex beat : The heart changes in 
form, increasing its long axis and its antero- 
posterior diameter and diminishing its transverse 
in systole, and at the same time changes in posi- 
tion, revolving on its axis, the apex being pro- 
jected forward 
Visibility of the apex beat. 
Normally the visibility varies with the 

Shape of the chest and the width of the 

intercostal spaces ; 
Thickness of the chest-wall from the 
presence of fat, muscle, and mammary 
gland ; 
Posture of the body, the apex being less 
visible in recumbency ; 

4 



50 PHYSICAL DIAGNOSIS OF THE CHEST. 

Force of the heart's action, as dependent 
upon its innate power and its excitation. 
Abnormally the visibility of the apex beat varies 
greatly. 

Very marked pulsation is usually observed 
in hypertrophy ; also where the lung is re- 
tracted from in front of the apex. 

Slight or absent pulsation is observed in 
Conditions of cardiac iveakness from 

1. General debility, or 

2. Local weakness of the heart's muscle, 
dependent upon cardiac atrophy ; cardiac 
degeneration, fatty, fibroid, or amyloid ; 
or cardiac dilatation. 

Interposition of air between the heart and 
chest-wall : emphysema, pneumothorax, 
pneumo-pericardium ; fluid : pleuritic or 
pericardiac effusion ; solids : tumors, 
fibrinous deposit. 
Thickening of the chest-wall: excessive fat, 
scleroderma, oedema, emphysema of the 
chest- wall. 
Displacement of the heart, as by traction 
from behind by fibroid contraction. 
Location of the apex beat. 

Normal Location of the Apex Beat. 

In the adult male it is in the fifth inter- 
costal space, two inches below and one inch 
inside the nipple line. Between two and 
a half and three inches from the mid- 
sternum. 
Variations from the position in the healthy 
adult male accord with 
Age : in children under ten years the apex 
beat is usually in the fourth intercostal 
space inside or outside the left mammillary 



METHODS OF PHYSICAL DIAGNOSIS. 51 

line ; in old age it is apt to be lower down, 
sometimes in the sixth intercostal space. 

Respiration. Deep inspiration may carry it 
down to the sixth interspace. 

Posture on the 

1. Left side, may carry it to the left of 
the nipple line. 

2. Right side, to the right of the usual 
position. 

Physical exertion or emotion. The apex beat 

may become stronger or broader, or may 

be carried to the left w T hen the individual 

is greatly excited. 

Abnormal Location of the Apex Beat ; it may 

be displaced, 
Upward. 

Pushed up by deformity of the chest- wall ; 
pericardiac effusion (here it is apparently 
so) ; abdominal tympanitis, tumors, and 
ascites ; paralysis of the diaphragm. 

Pulled upward by fibroid contraction of the 
upper lobe of the left lung. 
Upward and to the left. 

Pushed upward and to the left by hyper- 
trophy of the left lobe of the liver or by 
abdominal tumors. 

Pulled by fibroid contractions of the left 
lung. 
Downward and to the left. 

Pushed downward and to the left by de- 
formity of the chest-wall ; large aneurysm 
of the arch of the aorta ; mediastinal tu- 
mors ; right pleuritic effusion or pneumo- 
thorax ; hypertrophy of the left ventricle 
(strong apex beat) ; dilatation of the left 
ventricle (weak apex beat). 



52 PHYSICAL DIAGNOSIS OF THE CHEST. 

Pulled downward and to the left by fibroid 
contractions of the pleura and lung. 

TO THE RIGHT. 

Pushed to the right by deformity of the chest- 
wall, emphysema of the lungs, left pleuritic 
effusion, or pneumothorax. 
Pulled to the right by fibroid contractions 
of the right lung, or held by pleuritic 
adhesion. 
Located on the right side in transposition of 
the thoracic organs (a rare condition). 
PRECORDIAL movement may be observed together 
with the apex beat. The right auricle may rarely 
cause pulsation to the right of the sternum in the 
third and fourth interspaces. 

In Valvular Disease frequently ; in cardiac irrita- 
bility, especially in thin or young persons ; in 
adhesive pleurisy with mediastinal pericarditis, 
here there is usually a systolic drawing in of 
several intercostal spaces. 
In Infiltration of the Lung lying in front of the 

heart. 
In Empyema Yulsans, which may occur when 
pus in the pleural cavity lies in front of the 
heart, the cardiac movements being communi- 
cated to the fluid. It is probably favored by 
paresis of the intercostal muscles, high tension 
in the fluid and a powerful heart. 
EPIGASTRIC PULSATION. 

Hypertrophy of the Might Ventricle, especially 
if accompanied by pulmonary emphysema, fre- 
quently causes a systolic pulsation or trembling 
of the epigastrium. 
Pulsation of the Normal Heart may be trans- 
mitted to the epigastrium through an hyper- 
trophied left lobe of the liver. 



METHODS OF PHYSICAL DIAGNOSIS. 53 

Pulsation of the Normal Aorta may be seen in 
the epigastrium in thin persons, especially when 
the stomach is empty. 

Pulsation of an Abdominal Aneurysm of the 

aorta may be visible in the epigastrium. 
Venous Hepatic Pulsation, observed in the epi- 
gastrium, may occur in marked tricuspid in- 
sufficiency (rare). The whole organ seems to 
throb. The veins of the liver having no valves 
easily transmit the regurgitation, especially those 
of the left lobe, as it is smaller and most super- 
ficial. 

PALPATION. 

Palpation is the method of physical examination by the 
sense of touch, and it confirms much of what has been 
obtained by inspection ; it reveals 

SIZE, SHAPE, contour, roughness, etc. 

CONSISTENCE, pitting in superficial oedema, and fluctua- 
tion ; the latter may not only be made out in case of 
superficial collection of pus in the chest wall, but also 
sometimes in copious pericardial effusion, in the third, 
fourth, and fifth interspaces over the pericardium. 

MOISTURE AND HEAT; and elicits 

PAIN. 
Area. 

LOCALIZED, as in intercostal neuralgia (Valleix's 

three tender points). 
GENERAL sensitiveness, hyperesthesia. 

Depth. 

8 LPEEFICIAL. 

SKIN, inflammation. 
MUSCLE, pleurodynia. 

FRACTURE OF RIBS (crepitus, tenderness, disloca- 
tion). 



54 PHYSICAL DIAGNOSIS OF THE CHEST. 

DEEP-SEATED. 

PLEURA. 

MOVEMENTS. 
Muscular. 
Respiratory. 
Circulatory. 

CARDIAC MOVEMENTS, apex beat, precordial pul- 
sation . Palpable (or visible) precordial pulsation 
above the fourth rib may be due to aneurysm, or to 
dilatation of the auricle ; in the latter case the move- 
ment distinctly precedes the apex beat, in the former 
it is systolic. In some thin persons with vigorous 
hearts, but specially where there is retraction of the 
lung from in front of the heart, a perisystolic wave 
may be felt passing over the precordium from above 
downward. 
EXTENT. 
Localized. 
Diffused. 
CHARACTER. 
Intensity. 
Rhythm. 
VENOUS MOVEMENTS. 
ARTERIAL MOVEMENTS upon palpation 
AORTIC dilating pulsation of aneurysm, etc. 
PULMONARY ARTERY. Where the left lung is 
markedly retracted from the base of the heart 
this vessel may be felt to pulsate in the second 
left interspace close to the edge of the sternum. 
The diastolic shock of the closure of its valves 
is not infrequently felt in cases of high tension 
within this artery with an hypertrophied right 
heart, as typically occurs in mitral obstruction. 
CAROTID pulse. 
RADIAL pulse. 



METHODS OF PHYSICAL DIAGNOSIS. 55 

Factors in the Production of the Pulse. 

Force of the Heart's Beat. 

Elasticity of the Large Vessels. 

Resistance at the Valvular Orifices of the 

heart. 
Resistance in the Arterioles and capillaries. 
Volume of the Blood. 
Characteristics of the Pulse, as regards 
Quality of the pulse, degree of tension. 

Increased or high tension makes the in- 
compressible or hard pulse. Tension is in- 
creased more or less : 

1. By inspiration, being highest at the be- 
ginning of expiration, except in pulsus 
paradoxicus. 

2. By accelerated action of the heart and 
cardiac hypertrophy. 

3. By stimulation of the vaso constrictors, 
as by the action of cold, electricity, and 
certain drugs. 

4. By diminished outflow of blood at the 
periphery. 

5. By disease of the vessel walls : atheroma, 
sclerosis, old age ; drugs — e.g. lead-poison- 
ing. Arterio-sclerosis is marked by hard- 
ening of and irregular deposits of lime salts 
in the vessel wall, often feeling like suc- 
cessive rings, as of a diminutive trachea, 
and there is increased sinuosity in its 
course. None of these is present in sim- 
ple high arterial tension from other causes. 

6. By compression of the large arterial 
trunks, ligation, or pressure. 

7. By impeded venous flow, as in preg- 
nancy, constipation, chronic bronchitis, 
emphysema, nephritis, etc. 



56 PHYSICAL DIAGNOSIS OF THE CHEST. 

Decreased or low tension makes the com- 
pressible or soft pulse ; tension is decreased 
during expiration, being lowest : 

1. At the beginning of inspiration, except 
in pulsus paradoxicus. 

2. After a hemorrhage. 

3. By stoppage of the heart. 

4. In elevated parts of the body. 

5. By stimulation of the vaso-dilators, action 
of drugs. 

Fulness of the artery or volume of the pulse. 

Increased volume of the pulse makes the 
large or full pulse. This is seen in cardiac 
hypertrophy, plethora, early stage of chronic 
nephritis. 

Decreased volume of the pulse makes the 
small empty pulse as seen in general weak- 
ness from wasting disease, cardiac weakness, 
cardiac valvular lesions, aortic stenosis, mi- 
tral stenosis, or marked insufficiency with- 
out compensation. 

Alternate increase and decrease of 
the volume of the pulse is observed in 
aortic insufficiency, giving the collapsing or 
water-hammer pulse of Corrigan. 
Duration of each pulse-wave depends upon the 
dilatation of the artery by the blood-current, 
and its contraction during the passage of the 
blood into the capillaries, and also upon the 
length of time occupied by the ventricular 
systole. 

Prolonged duration of each pulse-wave, 
giving the slow or sluggish pulse, occurs in 
all diseases producing contraction of the 
smaller arteries, as nephritis, arterioscle- 
rosis, angina pectoris. 



METHODS OF PHYSICAL DIAGNOSIS. 57 

Shortened duration of each pulse-wave, 
giving the active, quick pulse, is present in 
all diseases and conditions giving relaxed 
arteries, as in febrile affections and in aortic 
regurgitation. It is usually low in tension. 
Force of each pulse-wave depends chiefly upon 
the energy of the cardiac systole, and also 
upon the amount of vascular tone. 

Increased force of each pulse- wave, making 
the strong pulse, occurs with increased car- 
diac energy and vascular tone. This is not 
necessarily large in volume, as the arterial 
wall may be contracted and rigid. 

Decreased force of each pulse- wave, making 
the weak pulse, is the result of cardiac de- 
bility. It is not necessarily small in vol- 
ume; the full bounding pulse with low 
pressure is often very feeble. 
Rhythm of the Pulse. 

Varieties of rhythm. 

Irregular pulse, as respects time, rate, and 
volume. 

1 . Irregular in time : varying length of 
successive intervals between beats, 
either rhythmical or arhythmical. Ir- 
regularity in rate may be manifested by 
change in rapidity from fast to slow or 
vice versa. 

2. Irregular in volume : varying strength 
or fullness of successive beats. 

(a) Pulsus bigeminus : beats occurring 
in pairs, with intervals between each 
pair, the second beat of each pair 
being weaker than the first. 

(b) Dicrotic pulse : characterized by a 
double beat — i. e., a large beat fol- 



58 PHYSICAL DIAGNOSIS OF THE CHEST. 

lowed by a small after-beat, occurring 
with each cardiac systole ; it is a weak 
pulse of low tension. It is obtained 
in fever patients and in some condi- 
tions of great exhaustion. 

(c) Pulsus trigeminus : groups of three 
beats, the groups being separated by 
intervals. 

(d) Intermittent pulse : here a beat is 
dropped out or is abortive, cardiac 
systole not being strong enough to 
send through the arteries a wave of 
sufficient size to be felt at the wrist. 

(e) Tremor cordis is a rapid fluttering 
action, with a corresponding series 
of weak rapid beats of the pulse, 
often scarcely perceptible, which 
suddenly attack a heart beating nor- 
mally. The paroxysm lasts for but 
a few seconds, and ends with an un- 
usually forcible beat. It seems gen- 
erally to be the result of flatulence 
or other gastric disturbance. 

(/ ) Pulsus paradoxicus : normally the 
volume of the pulse is increased 
during inspiration, and is diminished 
during expiration; but in pulsus para- 
doxicus it is decreased during in- 
spiration, the pulse being very small 
or even absent at that time. It de- 
pends upon diminished lumen of the 
aorta, and notably occurs in medias- 
tinal pericarditis, concretii pericardii, 
and with large pleuritic effusion, or 
even in adherent pericarditis (Gib- 
son). 



METHODS OF PHYSICAL DIAGNOSIS. 59 

(g) Irregularity or incoordination of 
the two radial pulses may be due to : 

1. Abnormal anatomic distribu- 
tion. 

2. Occlusion, partially or entirely , 
of one artery by embolism, 
thrombosis, sclerosis, or injury, 
or by pressure from aneurysm, 
tumors, or contraction of scar- 
tissue. 

(h) Recurrent pulsation in an artery 
may be felt sometimes in acute febrile 
affections, notably lobar pneumonia, 
and in aortic regurgitation, in the 
following manner : If two fingers 
are placed upon the radial artery, 
the proximal completely closing the 
vessel by pressure, a delayed feeble 
pulsation may be felt by the distal 
finger, owing to the passage of the 
wave from another artery by anasto- 
mosis, as by the palmar arch from 
the ulnar artery. 
Causes of broken rhythm of the pulse. 
General causes of broken rhythm. 

1. Nervous 1 . n , ,, 

^. , faction oi drugs or disease. 

2. Circulatory J & 

Local causes of broken rhythm. 

1. Keflex, dyspepsia, etc. 

2. Circulatory, diminished blood pressure 
in the arteries, as in ansemia. 

3. Cardiac weakness from 

(a) Degeneration, atrophy, etc. 

(b) Mechanical interference with its 

action ; 
Acting within the cardiac apparatus, 



60 



PHYSICAL DIAGNOSIS OF THE CHEST. 



due to valvular disease, pericardiac 
effusion. 
Acting from outside the heart : pleu- 
ritic effusion, distended stomach, 
hepatic enlargement, tumors, de- 
formities of the chest. 
Frequency of the Pulse, rate or number of 
beats. 
The average pulse rate in healthy adult 
males is seventy -one beats ; in females, 
eighty per minute ; the pulse is relatively 
more rapid also in infancy, in small persons, 
in the upright position, in high altitudes, in 
late periods of the day> after meals, during 
emotional excitement, intellectual exercise, 
or muscular exertion. 
The slow pulse, bradycardia, is character- 
ized by a rate of sixty beats or less per 
minute ; it has been observed as low as 
fifteen beats. It is 
Normal in 

1. Certain persons, habitually, apparently 
inherited. 

2. Women immediately after child-birth. 

3. Old age. 
Abnormal. 

1. Symptomatic in 

(a) General diseases and conditions at- 
tended by great exhaustion, e. g. con- 
valescence from acute fevers, typhoid, 
diphtheria, pneumonia, and in dia- 
betes and anaemia. 

(b) Digestive tract : aggravated dys- 
pepsia, gastric ulcer, cancer of the 
oesophagus. 

(c) Urinary tract : uraemia. 



METHODS OF PHYSICAL DIAGNOSIS. 61 

(d) Cardiac coronary sclerosis, myocar- 
dial degeneration, fatty, fibroid, etc., 
aortic stenosis. 

(e) Nervous system. 

Central diseases with gross lesions, 

as in early stage of meningitis, 

apoplexy, tumors of the cerebrum, 

injuries to the cervical cord. 

Peripheral, pressure upon the vagus 

by tumors, etc. 
Neuroses, so-called idiopathic disease 
of the nervous system — epilepsy, 
hysteria in certain cases, mania, 
general paresis, following fright. 
Toxic: tea, coffee, lead, uric acid 
(uraemia), bile (jaundice). 
The rapid pulse, tachycardia, is character- 
ized by a rate of eighty-five beats or more 
per minute ; it has been observed as 
high as two hundred and fifty beats in 
adults. 
Normally, the pulse is rapid in certain healthy 
adults habitually, and in certain indi- 
viduals who are able voluntarily to in- 
crease the rate of the heart ; in women at 
gestation : and in children as follows : 
Infants, 130 to 150. 

One year old, 120 to 130. 
Two years old, 105. 
Three years old, 100. 
Five years old, 90 to 94. 

Variations from emotions and phys- 
ical exercise, etc., vide the average 
pulse. 
Abnormally rapid pulse may be 
1. Symptomatic, arising from 



62 



PHYSICAL DIAGNOSIS OF THE CHEST. 



(a) Undue irritation of the nervous 
system, as related to 

Age : young rapidly-growing weak 
persons. 

Sex : women usually at establishment 
of menstruation and the meno- 
pause, especially when anaemic and 
chlorotic. 

Habits: venereal excess, masturba- 
tion. 

Toxic : tobacco, alcohol, tea, coffee. 

Fatigue : physical or mental. 

Fever. 
(6) Lesions of the cardiac nervous 
mechanism. 

Central : bulbar disease impairing 
the function of the vagus, tumors 
or swellings, softening in the 
medulla or cord, hemorrhage. 

Peripheral : tumors or swellings 
pressing upon the vagus, neuritis. 

Neuroses. 

Exophthalmic goitre. 

Epilepsy, hysteria, irritable heart 

of soldiers. 
Neurasthenia. 
2. Reflex. 

(a) Circulatory : lesions of the heart or 
vessels. 

(b) Respiratory : nasal growths and 
hypertrophies, pharyngeal and laryn- 
geal disorders. 

(c) Gastro-intestinal : dyspepsia, intes- 
tinal worms in children. 

(d) Genito-urinary : ovarian and uter- 
ine disease, nephritis, phimosis. 



METHODS OF PHYSICAL DIAGNOSIS. 63 

Fremitus is a trembling felt by the hand on examination. 
It has been termed fremissement cataire from its like- 
ness to the vibration felt upon the back of a purring 
cat. 

CIRCULATORY FRE3IITUS or thrill is due to 
vibrations originating within the heart or great ves- 
sels, and it includes : 

ANEURYSMAL or VASCULAR FREMITUS, sometimes 
felt over large superficial aneurysms, and occa- 
sionally over the carotids in valvular disease of 
the heart, and over the jugular veins in tricuspid 
insufficiency ; also, over the jugulars in case of 
constriction of these vessels from pressure, as in 
enlargement of the thyroid gland ; over the carotids 
and subclavian arteries (systolic) in free aortic re- 
gurgitation from the sudden filling of the relatively 
empty vessels. 
ENDOCARDIAL or CARDIAC FREMITUS, not infre- 
quently obtained, upon palpation of the prsecordia, 
in certain valvular lesions. 

Causes of Cardiac Fremitus : like certain cardiac 
murmurs, it may be due to the whirling of the 
blood-stream against a roughened surface or past 
a constriction. 
Frequency of Cardiac Fremitus. 

It generally occurs with loud cardiac murmurs, 
but comparatively few murmurs are accom- 
panied by a thrill. 
It is most common with mitral obstruction 

(presystolic) and aortic obstruction (systolic). 
It is more rare with aortic regurgitation (dias- 
tolic), mitral regurgitation (systolic). 
It is very rare with lesions of the right heart. 
Location of Cardiac Fremitus. 

It is generally felt best when the murmur is 
heard loudest — e. g., just above the apex in 



64 PHYSICAL DIAGNOSIS OF THE CHEST. 

mitral obstruction ; in the aortic area in aortic 
obstruction and atheroma. 
Intensity of Cardiac Fremitus. 

It is apt to be, like Murmurs, increased by ex- 
ertion. 
It may disappear in cardiac weakness, and re- 
turn with reviving strength or upon excitement. 
FRICTION FREMITUS is a rubbing or grating sen- 
sation felt by the hand in palpation over a part where 
two roughened, inflamed, serous surfaces are moving 
upon each other, as in the first stage of pleurisy, oc- 
casionally in pericarditis, and rarely in peritonitis. 
The crepitus produced by the rubbing together of 
fragments of broken ribs or other bones may be men- 
tioned as a variety of friction-fremitus. 
RHONCHAL, BRONCHIAL, or rale FREMITUS 
is caused by the passage of air through fluid in the 
trachea and larger bronchi during respiration ; the 
vibrations produced are sometimes so marked as to 
be felt by the hand upon palpation. 
CAVERNOUS FREMITUS: this may sometimes be 
felt over superficial cavities in the lung, owing to the 
vibration of fluid within them. 
HYDATID FREMITUS, or thrill, may sometimes be 
felt over a large superficial hydatid cyst. Two fingers 
should be placed over the part, one firmly pressed, 
the other lightly. If the former be percussed, a thrill 
may be felt in the latter immediately following the 
percussion-stroke. 
VOCAL FREMITUS, variously termed voice frem- 
itus, vocal vibration or pectoral fremitus, is a trem- 
bling felt by the hand when placed upon the chest of 
a person who is speaking aloud (tussive or cough 
fremitus is of the same nature). 
INTENSITY OF VOCAL FREMITUS. 
Increased or marked vocal fremitus. 



METHODS OF PHYSICAL DIAGNOSIS. 65 

Normal, is found with 

L/OW PITCHED VOICES, 

Strong voices ; near to the 

Larynx ; over the 

Teachea and 

Great bronchi ; it is more marked over the 

Eight apex of the lung than over the left, 

owing to the size and direction of the right 

bronchus ; it is more marked over 
Thin chests from the absence of muscle or 

fat, 
Abnormal, increased vocal fremitus is found : 
Over consolidation of the parenchyma of 

the lung, when the bronchial tubes, of large 

and medium size, are patulous, as obtains in 

phthisis and pneumonia ; 
Over compressed or collapsed lung above 

the level of the effusion ; 
Over a cavity near the surface, with dense 

walls and a free opening into a large 

bronchus. 
Diminished or Suppressed vocal fremitus. 
Normal, vocal fremitus is weak or absent with 
High pitched voices ; 
Weak voices; 

Women, over lower half of chest ; 
Children, over the whole chest ; and at a 
Distance from the larynx and large 

bronchi ; over 
Thick chest- walls from excess of fat, mus- 
cle, or mammary gland. 
Abnormal, diminished vocal fremitus is due to 
Interposition of 

Fluid, as in hydrothorax, pleurisy with eifu- 
sion, etc. ; 

Air, as in emphysema, pneumothorax ; 



66 PHYSICAL DIAGNOSIS OF THE CHEST. 

Solids, as in adherent and markedly thick- 
ened pleura, large solid tumor. 
Obstruction of the labge bronchial 
tubes from the presence of a foreign body, 
or compression by a tumor or stricture. 

MENSURATION. 

Measurement determines size and the symmetry or asym- 
metry of the chest ; in the latter case it is instituted from the 
middle point behind to the middle point in front. 

PEKCUSSION. 

Percussion is the art of eliciting sounds by striking the 
body. 

METHODS of percussion. 

Immediate, striking directly upon the part; this method 

is of comparatively little use. 
Mediate, striking upon an intermediate object held against 

the part. 

INSTRUMENTS, in mediate percussion (varieties). 
Hammer, plexor or plessor. 

Plexi meter, or plessimeter, the medium upon which the 
hammer strikes. 

THE NATURAL and most useful instruments are the 

middle or index fingers of one hand, serving as plexor, 

and one or more fingers of the other hand, as pleximeter. 

ARTIFICIALLY, they may be made of hard rubber, 

wood, etc. 

RULES FOR PERCUSSION. 
The Patient. 

THE SURFACE should be bare of clothing. 
THE LIMBS symmetrical, the same position being 
maintained in the examination of the two sides. 



METHODS OF PHYSICAL DIAGNOSIS. 67 

TO EXAMINE THE FRONT of the chest the arms 

should be at the sides. 
TO EXAMINE THE BACK the arms should be folded 

in front. 
TO EXAMINE THE SIDES the arms should be folded 

above the head. 
POSITION OF THE BODY. 

EASE OF POSITION, to avoid discomfort and to in- 
sure like muscular tension on the two sides. 
POSTURE: the erect, recumbent, or sitting posture, 

or all these may be required, as in determining 

change of position of solid organs or of the level 

of fluids ; recumbency must be maintained if there 

is danger of heart failure. 
The Examiner should maintain a position symmetrical 
with regard to the patient, the ear being at the same 
relative distance from the points percussed. 
The Instruments (their use). 

THE PLEXI3IETER should be applied 

WITH FIRMNESS, to avoid a cushion of air beneath 

it ; the firmness of pressure should be uniform at 

all points of percussion. 
PARALLEL TO THE RIBS, upon or between them. 
OVER SYMMETRICAL POSITIONS on the two sides 

of the chest for comparison. 
THE FLEXOH and its use : 

THE STROKE should be made WITH THE ENDS OF 

THE FINGERS rather than with their pulps. 
THE STROKE should be made PERPENDICULARLY 

to the surface. 
THE STROKE should be REBOUNDING, in using the 

hand the motion should be FROM THE WRIST. 
THE STROKES should be MODERATELY RAPID in 

succession. 
THE STROKE should be made with MODERATE 



68 PHYSICAL DIAGNOSIS OF THE CHEST. 

FORCE, never causing pain, but more forcible for 
sounding deep-seated organs than for superficial. 
THE TWO SIDES SHOULD BE PERCUSSED IN 
LIKE STAGES OF RESPIRATION, preferably at 
the end of expiration. 

PERCUSSION SOUNDS. 

The Elements of Sound in percussion. 

QUALITY, the characteristic property or chief attribute 
which distinguishes one sound from another — e. g. 
full, empty, shallow, clear, soft, hard, toneless, dead, 
" thigh sound. " 
INTENSITY, the quantity or loudness, largely govern- 
ing the distance at which a sound can be heard ; 
varying with 
THE FORCE OF THE BLOW. 
THE VOLUME OF AIR under the part. 
THETHINNESSAND ELASTICITY OF THE CHEST- 
WALL. 
DURATION, the length of time a sound can be heard. 
PITCH, the degree of elevation in the musical scale. 
ITS RELATION to duration and intensity, the lower 
the pitch the longer the duration, and the greater 
the intensity, and per contra. 
THE FACTORS IN ITS PRODUCTION. 

The Larger the Cavities (containing gas) in the 

part, the lower the pitch, and per contra. 
The Greater the Tension of the Inclosing Wall, 

the higher the pitch, and per contra. 
Proximity of Solid Bodies elevates the pitch. 
The Larger the Opening in a cavity, the higher 
the pitch. 
The Varieties of Percussion Sounds. 

NORMAL PULMONARY OH VESICULAR 
RESONANCE or lung sound. 
LOCATION, over those parts of the healthy lung 



METHODS OF PHYSICAL DIAGNOSIS. 69 

which do not overlap the heart, liver, or spleen, 
and which are not covered by the scapulae (vide the 
landmarks). The resonance obtained over the lung 
which overlaps these organs, while normal vesicular, 
is relatively less resonant, and hence properly 
termed dulness. Resonance is less intense and 
higher in pitch over the right apex than over the left. 
CAUSE of the normal vesicular resonance ; it is prob- 
ably due to the combined vibration of the walls of 
the chest, alveoli, and bronchi and the air con- 
tained within them, the resonance of the deeper 
parts being modified by the thickness of the fleshy 
parts and by the elasticity of the bony elements. 
CHARACTER of normal vesicular resonance. 
Quality, soft, clear, full, resonant, vesicular. 
JPitcJi, low. 
Intensity, great. 
Duration, long. 
VARIATIONS IN CHARACTER. 
In the Same Individual. 

In a Given Location vesicular resonance varies 

with the degree of respiratory expansion. 
In Different Locations it varies according to 
the size or amount of lung under the part and 
the thickness of the chest-wall. 
In Different Individuals it varies according to 
the same factors. 
EXAGGERATED PULMONARY RESONANCE. 
LOCATION. 

Normal, over both lungs in children. 
Abnormal. 

Over both Lungs in marked anaemia, in em- 
physema (the resonance present in this disease 
has also been termed by Flint vesiculotym- 
panitic). 
Over One Lung* when the other is partially or 



70 PHYSICAL DIAGNOSIS OF THE CHEST. 

wholly crippled by consolidation, compres- 
sion, etc. 
Over Sound Parts of a crippled lung. 
CAUSE, the lung is over-distended with air, either 
functionally, or from organic trouble as in em- 
physema. In children it is due to the thinness 
and resonance of the chest wall. 
CHARACTER : this is like that of vesicular resonance, 
except for increase of intensity and duration and 
slightly lower pitch. 
VARIATIONS IN CHARACTER accord with the 
amount of air in the part, within reasonable limits. 
BOJSTE RESONANCE. 

LOCATION, over the sternum and clavicle, and to a 

slight extent over the ribs. 
CHARACTER. 

Quality, non-tympanitic, resonant, ringing. 
Pitch, higher than that of vesicular resonance. 
Intensity, less than that of vesicular resonance. 
Duration, shorter than that of vesicular resonance. 
DULNESS, diminished resonance. It includes vesic- 
ular and tympanitic dulness. 
LOCATION. 

Normal Vesicular Dulness is obtained where the 
lung overlaps the heart, liver, and spleen and 
underlies the scapulae. Normal tympanitic dul- 
ness is found over the lower part of the liver, 
heart, and spleen when the stomach and colon 
are distended with gas. 
Abnormal Vesicular Dulness is obtained over 
Thickening 1 of the Chest-wall from oedema, 

tumor, or inflammatory swelling. 
Interposition, between the lung and chest-wall, 
of solids or fluids ; a moderately thick layer 
of inflammatory lymph on the pleural surface ; 
a moderate amount of pleuritic effusion, in- 



METHODS OF PHYSICAL DIAGNOSIS. 71 

flammatory or non-inflammatory ; extra-pul- 
monary tumors of small size. 
Consolidation of the Lung-, moderate in amount: 
pneumonia, tuberculosis, syphilis, new growths, 
oedema, pulmonary hemorrhage, collapse of 
lung. 
CAUSE, less air or relatively more solids beneath the 

part than in normal lung. 
CHARACTER. 

Quality, harder, emptier, less clear, less vesicular 

than normal pulmonary vesicular resonance. 
Pitchy higher. 
Intensity, less. 
Duration, shorter. 
VARIATIONS, in character in different individuals 
and in different localities, accord with the relative 
amount of air or solids, approaching the character 
of pure pulmonary resonance on the one hand and 
flatness upon the other. 
FLATNESS. 
LOCATION. 

Normal, over those organs or parts containing no 
air, hence over that portion of the heart, liver, 
spleen, and kidneys uncovered by lung. 
Abnormal, over the chest when there is an exag- 
geration of any of those morbid conditions which 
in a slight degree produce dulness : pleurisy with 
effusion, emphysema, hydro-thorax, etc. 
CAUSE, entire absence of air or gas in and for some 
distance beneath the organ under the part percussed. 
CHARACTER. 

Quality, hard, empty, muffled, non-resonant, the 

" thigh sound." 
Pitch, very high, highest of all percussion notes. 
Duration, very short. 
NO VARIATIONS OF ITS CHARACTER, as such, 



72 PHYSICAL DIAGNOSIS OF THE CHEST. 

occur ; it may be modified by tympanitic resonance, 
where hollow gas-containing organs like the stom- 
ach or colon underlie a solid organ like the liver ; 
it is then termed tympanitic dulness, really a modi- 
fication of tympany. 
TYMPANITIC RESONANCE or tympany. 
LOCATION. 
Normal, where the stomach or colon, distended 
with gas, underlies the infra-mammary, infra- 
axillary, and infra-scapular regions, and some- 
times over the lower part of the mammary and 
inferior sternal regions ; also over the trachea. 
Abnormal. 

Over a part of the chest when Gas is present 

in the Pleural Sac, pneumo-thorax. 
Over a Pulmonary Air-containing Cavity of 

large size, phthisis, abscess. 
Complete Solidification of a Part of the upper 
lobe of the lung, tympany being obtained from 
the trachea beneath (" tracheal tone " of Wil- 
liams), second stage of pneumonia, phthisis. 
Bronchiectasis with surrounding solidification, 

interstitial pneumonia. 
Conduction of Stomach Resonance high up 
on the left side, when the lower lobe of the 
left lung is solidified. 
CAUSE, percussion over a hollow gas-containing or- 
gan or cavity, the walls of which are more or less 
thin and tense. 
CHARACTER. 

Quality, non-vesicular, resonant, ringing, but 

harder than vesicular resonance. 
Pitch, higher than vesicular resonance, variable. 
Intensity and duration variable. 
VARIETIES OF TYMPANY. 

Closed Tympany is the sound obtained by percus- 



METHODS OF PHYSICAL DIAGNOSIS. 73 

sion over a cavity filled with gas, and not com- 
municating freely by an opening with the ex- 
ternal air — e. g., the stomach and colon. It is 
obtained also in some cases of pneumothorax. 
Open Tympany includes amphoric and cracked- 
metal resonance. 
Amphoric Resonance is obtained over a cavity 
with a large opening, as in percussion of the 
cheeks with the mouth open. 
Location. 

Normal over the trachea, and sometimes 
over the upper part of the chest in chil- 
dren. 
Abnormal , abscess or tubercular cavity com- 
municating with a large bronchus. 
Cause, percussion over a moderate sized gas- 
containing cavity with rigid, non-collapsing 
walls and free communication by a large 
opening ; the examiner's ear or the mouth 
of the stethoscope should be near the 
patient's open mouth. 
Character, its quality is tympanitic but pe- 
culiarly ringing and hollow like the sound 
produced by blowing across the mouth of a 
bottle ; its pitch is higher than vesicular res- 
onance, but varies with the size of the cavity 
and of the opening, and the condition of the 
adjacent lung. Its intensity and duration 
are variable. 
Change in the Character of amphoric 
resonance. 
WintricNs change of sound only occurs over 
a cavity w 7 hich freely communicates with 
a bronchus ; a louder, more amphoric, and 
higher-pitched note is produced over a 
cavity when the mouth is open, especially 



74 PHYSICAL DIAGNOSIS OF THE CHEST. 

with the tongue protruding. The note 
with the mouth closed may be dull but 
slightly tympanitic. 

Williams 7 tracheal tone, or change of sound, 
so called, is the tympanitic note obtained 
by percussion over the trachea, its change 
in character being similar to that in Wint- 
rich ? s change of sound. 

Interrupted Wintrieh's change of sound (Ger- 
hardt, Moritz). This differs from the 
former in that the change is marked in 
some positions of the body, in others in- 
distinct or absent owing to the closure of 
the opening by the secretions within the 
cavity. 

Gerhardt's change of sound. A tympanitic 
sound, whether open or closed, may change 
in pitch with change in posture. This 
may be due to the change in the tension 
of the chest-wall and that of the cavity, 
and to the change in location of fluids 
within the cavity. 

Friedreich's, or the respiratory change of 
sound. A tympanitic note over the lung, 
or over a cavity within it, is higher in 
pitch at the end of deep inspiration than 
in expiration, due probably to the higher 
tension. 
Cracked-metal Resonance is a form of open 

tympany, and may be imitated by striking 

upon the knee w r ith the hands loosely clasped 

palm to palm. 
Location and Cause. 

Normal. 

1. If the chest be covered with much 
hair, under percussion. 



METHODS OF PHYSICAL DIAGNOSIS. 75 

2. If the pleximeter be loosely applied. 

3. Sometimes it is obtained over the upper 
part of the chest of children, especially 
when crying. 

4. Sometimes in adults when singing a 
prolonged note. 

Abnormal. 

1. Over some air-containing pulmonary 
cavities communicating with a bronchus 
by a small opening ; percussion should 
be firm, and during expiration, the 
patient's mouth being open. 

2. Occasionally in pleurisy, over the lung 
above the effusion; sometimes in the 
engorgement stage of pneumonia. 

3. When an opening exists through the 
chest-wall into the pleural sac. 

PERCUSSION OF THE NORMAL CHEST as a whole. 
With the foregoing principles as a guide, beginning at the 
apices of the lungs, compare the one with the other re- 
peatedly, both during full inspiration and forced expira- 
tion, and with the mouth open and closed if distinct 
dulness be found. The lungs are slightly more resonant 
in all their parts at the end of full inspiration than at the 
end of forced expiration. Pass downward, comparing 
like parts of the two lungs, and successive parts of each 
lung with those above — interspace with interspace, rib 
with rib. The resonance above the third ribs should be 
well marked and alike on the two sides, except that the 
note is apt to be appreciably duller over the right than 
over the left apex, owing to its relatively lower position 
and its nearness to its correspondingly larger main bron- 
chus. The note is a little duller above and over the 
clavicle than in the infraclavicular region, and it grows 
a trifle duller at the border of the sternum. Over this 



76 PHYSICAL DIAGNOSIS OF THE CHEST. 

the vesicular resonance is somewhat muffled by the dull 
tympanitic note of that bone and the resonance of the 
trachea. The interspaces give clearer vesicular resonance, 
of a lower pitch, than the ribs. On the left at the upper 
margin of the third rib the note becomes duller, and 
grows more so down to the fifth rib in the parasternal 
line, where the note becomes well-nigh flat over the heart 
below the margin of the lung. It continues so downward 
over the left lobe of the liver, the transition from heart to 
liver being therefore impossible to recognize. The flatness 
of this region is usually modified slightly by the nearness 
of the adjacent borders of the lung and the tympany of 
the underlying stomach ; hence the term superficial car- 
diac dulness, as compared to deep cardiac dulness obtained 
where the lungs overlap the heart. This area of cardiac 
flatness terminates upon the right at about the left sternal 
line, where the dull sound of that bone begins to be 
modified by the resonance of the right lung. Toward 
the left, vesicular resonance is obtained a little to the 
right of the apex beat, and extends to the left border of 
the heart, a trifle within the nipple-line. From this to 
the left, vesicular resonance is pure as in the infraclavic- 
ular space, and it is obtained laterally and posteriorly as 
well, above the level of the ninth rib. Below this, in the 
infrascapular region, the percussion note of the lung over- 
lapping the spleen down to the tenth rib is increasingly 
dull (splenic dulness), merging into flatness below. In 
front of the spleen, and below the margin of the lung to 
the left of the left lobe of the liver, and above the costal 
arch, is the " semilunar space of Traube." The percus- 
sion note here is usually tympanitic from the gas con- 
tained in the underlying stomach and colon, unless these 
be well filled with solids or liquid, or the greater omen- 
tum is loaded with fat, when the note will be flat or 
markedly dull. 

In the scapular, suprascapular, and interscapular regions 



METHODS OF PHYSICAL DIAGNOSIS. 77 

vesicular resonance is somewhat less distinct than in the 
infraclavicular and axillary regions, owing to the presence 
of the scapula with its under and overlying muscles and 
the greater thickness of the other dorsal musculature. 
Vesicular resonance posteriorly is therefore clearest in the 
infrascapular region of the left side above the ninth rib. 
Upon the right posteriorly the note is dull below the 
eighth rib, becoming gradually duller to the tenth, be- 
tween which levels the liver is overlapped by the lung. 
Above the eighth rib, on the right, resonance is nearly 
like that upon the left, except a very trifle duller. 

Anteriorly and laterally, upon the right side, vesicular 
resonance is marked above the fourth interspace in the 
nipple-line and the sixth rib in the mid-axillary line. 
Below this it becomes steadily duller over the liver to the 
lower margin of the lung, at the sixth and eighth ribs in 
the mammillary and mid-axillary lines, below which 
hepatic flatness prevails to the costal arch. For a space 
half an inch in breadth along the right margin of the 
sternum in the right mammary region slight dulness may 
often be obtained over the right auricle. Upon deep 
respiration the lower border of the lungs fluctuates an 
inch or two above and below its average position, as 
determined by percussion at the end of full inspiration, 
and again at the end of forced expiration. 

The infra-regions of the chest may be more or less 
tympanitic, according to the inflation of the stomach and 
bowel with gas. Hepatic, cardiac, and splenic flatness 
then gives place to tympanitic dulness, specially on forcible 
percussion, and the vesicular dulness of the lower part of 
the lungs becomes rather vesiculotympanitic. 

Percussion of the spleen should be done both in the 
right diagonal and upright postures. In the upright post- 
ure the spleen-lung angle is in the mid or posterior axil- 
lary line ; in the diagonal posture it is in the mid or ante- 
rior axillary line, owing to the slight change in the relation 



78 PHYSICAL DIAGNOSIS OF THE CHEST. 

of the spleen to the lung. To determine the size of the 
spleen, percuss downward from the apex of the spleen- 
lung angle. This should be done lightly, so that the com- 
parative flatness of the spleen may contrast w r ith the res- 
onance above the border of the lung, and the usual 
tympany yielded below the lower border of the spleen 
over the relatively superficial colon. This vertical dis- 
tance of splenic flatness should be 4 to 6 cm. in the 
upright, and 5 to 7 cm. in the diagonal posture, or at 
the most should not exceed 9 cm. 

Next percuss in the horizontal line on a level with the 
anterior end of the tenth rib, beginning anteriorly over 
the usual tympany of the underlying colon or stomach, 
and proceeding posteriorly till the flatness, or, at best, the 
tympanitic dulness of the margin of the spleen contrasts 
with the tympany in front of it. Splenic flatness ter- 
minates behind and above in vesicular dulness of the 
overhanging lung. 

With the landmarks of the chest and the principles of 
percussion in mind, and a knowledge of the percussion- 
notes normally obtained over every part, one is prepared, 
if familiar with the mechanical changes incident to disease, 
to explain the presence of abnormal vesicular or tympanitic 
resonance, or of flatness, or of dulness. 

AUSCULTATION. 

METHODS of auscultation. 
Immediate or direct. 
Mediate or indirect. 

INSTRUMENTS of mediate auscultation, the stethoscope. 
Varieties. 

UNIATJRAL, hollow and solid. 

BINAURAL, Knight's, Camman's, Denison's, Alli- 
son's differential, Corwin's single, double, and multi- 
plex stethoscopes. 



METHODS OF PHYSICAL DIAGNOSIS. 79 

Objections to the stethoscope. 

IT HAS A SPECIAL RING or roaring sound like a 
shell. 

OFTEN FOORLY MADE. 

FRIGHTENS CHILDREN. 

NOT ALWAYS AT HAND. 
Advantages of the stethoscope. 

SHUTS OUT OUTSIDE SOUNDS. 

CONCENTRATES and circumscribes sounds. 

INTENSIFIES sounds. 

CERTAIN FARTS OF THE CHEST ARE INAC- 
CESSIBLE to the unaided ear. 

IT IS S031ETIMES INDELICATE to apply the 
ear directly to the chest. 

IT IS SOMETIMES UNPLEASANT and may be 
DANGEROUS to apply the ear to the chest. 
RULES for auscultation. 

The Patient should have regard to 

SYMMETRY, immobility, and ease of position. 

THE CHEST SHO ULD BE BARE for mediate aus- 
cultation, and should have a single layer of thin soft 
covering for immediate auscultation. 
The Examiner should have 

THE HEAD on a plane higher than the body to pre- 
vent congestion of the auditory apparatus ; 

THE ATTENTION concentrated upon one sound or 
set of sounds at a time. 
The Instruments. 

THE EAR-FIECE should fit the external meatus ac- 
curately and point in the same direction as the canal, 
downward and forward. It should not be so small 
as to penetrate far into the external auditory canal, 
as it is under these circumstances very uncomfortable 
and irritating. 

THE TUBES should be, in lumen, the size of the ex- 
ternal auditory canal ; it is of no advantage to have 



80 PHYSICAL DIAGNOSIS OF THE CHEST. 

them larger. The flexible portion of these tubes is 
best made of rubber, as this may be easily replaced 
at small expense. It should be pure in quality, and 
the walls sufficiently thick to allow free bending of 
the tube without causing it to collapse. 

THE LAB GEM CHEST-PIECE should not exceed 
one and one-fourth inch in diameter at the distal end. 
It is designed for the lung sounds. 

THE SMALLER CHEST-FIECE is especially de- 
signed for the sounds of the heart and vessels. But 
it answers very well for auscultation of the lungs. 
The chest-piece should fit accurately the surface to 
which it is applied. 

THE ENTIRE LENGTH of the instrument from ear- 
piece to chest-piece should not exceed about twenty- 
two inches, eighteen is better (vide cut of simple com- 
pact stethoscope, which the author has found a most 
satisfactory combination). 
The Act of auscultation. 

THE ROOM should be quiet. 

THE EAR OF THE STETHOSCOPE should be 
firmly.applied to the chest. 

THERE SHOULD BE NO FRICTION between 
parts of the instrument ; between the chest and the 
instrument ; between the hand and the instrument ; 
between the hand and the chest ; between the hand 
and the clothing ; between the chest and the clothing. 

THE MUSCLES of the upper extremity should be 
at perfect rest, to avoid as far as possible muscular 
sound. 

CORRESPONDING FARTS OF THE CHEST 
should be compared, and in like stages of respiration. 

THE ENTIRE CHEST should be examined. 

SOUNDS HEARD upon auscultation. 
The Elements of sound, 



METHODS OF PHYSICAL DIAGNOSIS. 81 

QUALITY, >| 

ORATION, \ Vide Passion sounds ' 
INTENSITY, J 

RHYTHM is the relation of sounds to each other, as 
that of inspiration to expiration, or the relation of the 
first and second sounds of the heart. 
Varieties of Sounds upon auscultation. 
PULMONARY sounds. 

RESPIRATORY sounds vary in kind, intensity, and 
rhythm. 
Kinds or Varieties of Respiratory Sound. 
Normal Vesicular Breathing (persons should 
breathe more forcibly than usual, but with 
the same rhythm). 
Locality : it is heard in its purity over the 
parenchyma of the lung away from the main 
bronchi ; best in the infra-scapular regions. 
Cause of the vesicular sound (opinion varies). 
It may be produced at the glottis, and mod- 
ified by conduction through the spongy 
tissue of the lung. 
It may be due to the entrance of air into the 

alveoli during dilatation. 
It may be due to the vibration of the lung 
substance from increased tension in in- 
spiration and the reverse in expira- 
tion. 
Character. 

Inspiratory sound. 

Quality, breezy, rustling, soft, vesicular. 
Pitch, low compared with that of laryn- 
geal breathing. 
Intensity, variable. 

Duration, coincident with the inspiratory 
act. 



82 PHYSICAL DIAGNOSIS OF THE CHEST. 

Expiratory sound. 

Quality, like the inspiratory but less vesic- 
ular. 
Pitch, lower than that of the inspiratory 

sound. 
Intensity, variable; the sound may not 

be appreciable but is generally so. 
Duration, much shorter than the expira- 
tory act. 
Rhythm : the ratio of the inspiratory to 
the expiratory sound is about three 
to one, there being a slight interval 
between them. 
Variation in character largely depends upon 
the nearness of the point of auscultation 
to the large bronchi. In muscular sub- 
jects, especially toward the end of 
forced inspiration, there is, in addition 
to the respiratory sounds, a soft rum- 
bling sound due to action of the chest 
muscles. 
Bronchial Breathing*. 
Locality and Cause c 

Normal, heard over the trachea. 
Abnormal (as a sign of disease), heard over 
consolidated lung, the main bronchi lead- 
ing to which are patulous, consolidated 
lung being a better medium of conduction 
of the sound from the larynx. It is heard 
in pneumonia and phthisis. 
Character, it is substantially like that of 
tracheal breathing, though slightly less in- 
tense. 
Laryngeal and Tracheal Breathing 1 differ from 
each other but little. 
Locality, heard over the larynx and trachea. 



METHODS OF PHYSICAL DIAGNOSIS. 83 

Character. 

Inspiratory sound. 

Quality, tubular, blowing, but changing 
in harshness with the force of the act. 
Pitch, higher than that of the inspiratory 
sound of normal vesicular breathing, 
and varying in pitch with the force of 
the act. 
Intensity, great but variable. 
Duration, a little shorter than the inspira- 
tory act. 
Expiratory sound. 

Quality, very similar to that of inspiration. 
Pitch, higher than that of inspiration. 
Intensity, greater than that of vesicular 

breathing. 
Duration, longer than that of the expira- 
tory sound of vesicular breathing. 
Rhythm : the expiratory sound is as long 
as the inspiratory, and a short interval 
exists between them. 
Cavernous Breathing-. 

Locality (it is an abnormal sound) heard 

over some pulmonary cavities. 
Cause, empty pulmonary cavity with easily 
collapsing and expanding walls in expira- 
tion and inspiration. 
Character. 

Inspiratory sound. 

Quality, soft, blowing, or puffing, but 

neither vesicular nor tubular. 
Pitch, low. 

Intensity, variable, but usually slight. 
Duration, variable. 
Expiratory sound. 

Quality, like that of the inspiratory sound. 



84 PHYSICAL DIAGNOSIS OF THE CHEST. 

Pitch, lower than that of the inspiratory 

sound. 
Intensity, variable, but usually slight. 
Ehythra : the expiratory sound is about 
the same length as the inspiratory. 
Broncho-cavernous Breathing'. 

Locality and Cause, cavity surrounded by 
solidified lung, as is found sometimes in the 
late stage of tuberculosis, abscess, or gan- 
grene. 
Character, both cavernous and bronchial 

elements are heard together. 
Varieties, metamorphosing breathing ; here 
the inspiratory sound is bronchial at first, 
but suddenly becomes cavernous. 
Vesiculo-cavernous. 

Locality and Cause, cavity covered by more 

or less healthy lung. 
Character, as indicated by its name. 
Amphoric Breathing*. 

Locality, over a large cavity with relatively 
rigid walls and with a large opening, as may 
be obtained in tuberculosis and occasionally 
in pneumothorax. 
Cause, the peculiar vibration of air in its 
passage in and out of, or across the mouth 
of a flask-like cavity. 
Character. 

Inspiratory sound most distinct. 

Quality, musical, hollow, metallic, harder 

than that of cavernous breathing. 
Pitch of expiratory sound lower than that 

of bronchial breathing. 
Intensity, usually greater than that of 

cavernous breathing. 
Rhythm : amphoric breathing is usually 
heard best in inspiration. 



METHODS OF PHYSICAL DIAGNOSIS. 85 

Intensity of Respiratory Sounds. 

Exaggerated, Supplementary, or Puerile 
Breathing". 
Locality. 

Normal in childhood, the chest-walls being 

thin and elastic. 

Abnormal, over one lung when the other is 

crippled by consolidation, obstruction, 

etc. ; over healthy parts of a crippled lung. 

Cause, the lung is performing more than its 

usual function. 
Character, like that of normal vesicular 
breathing, except of greater intensity ; both 
inspiratory and expiratory sounds are louder 
and longer than usual. 
Feeble Respiration. 
Locality. 
Normal. 

Over thick chest-walls, as in muscular or 
fat persons; over the female mammae 
and over the scapulae. 
At a distance from the large bronchi, over 
the lower part of the chest, especially 
in women. 
In superficial breathing. 
The vesicular murmur is normally less 
intense on the right than on the left 
side. 
Abnormal from 

Imperfect transmission, due to oedema or 
swelling of the chest-walls ; air, fluid, 
or inflammatory lymph in the pleural 
sac. 
Loss of elasticity of the lung, emphysema. 
Partial blocking of the air-cells with blood 
or serum, as in pulmonary oedema. 



86 PHYSICAL DIAGNOSIS OF THE CHEST. 

Consolidation of lung with filling up of 

the bronchi. 
Obstruction of the larynx, trachea, or 
bronchi from a collection of pus, mucus, 
blood, or fibrin ; foreign body ; thick- 
ening of the mucous membrane ; pres- 
sure of tumors. 
Constriction of the tubes from muscular 

contraction, asthma, bronchiolitis. 
Deficient action of the respiratory muscles. 
Mechanical obstruction, as in tympany, 

ascites, abdominal tumors. 
Pain, as in pleurisy, peritonitis, pleuro- 
dynia, neuralgia. 
Paralysis of the diaphragm. 
Suppressed Respiratory Sound ; entire absence 
of respiratory sounds. 
Locality and Cause, an exaggeration of the 
conditions which produce feeble respiration : 
pneumo-thorax, hydro-thorax, occlusion of 
the larger air-passages. 
Rhythm of Respiratory Sounds. 

Interrupted, Jerking, Wavy or Cog-Wheel 
Respiration. 
Locality. 

Normal, in nervous persons, agitated by ex- 
amination ; here it is apt to be heard more 
or less over the whole chest, but it may 
be localized ; sometimes it is heard in 
healthy persons from no apparent cause. 
Abnormal, it may accompany : 

Pain, as in pleurisy, pleurodynia, inter- 
costal neuralgia ; it is generally heard 
over the whole chest. 
Phthisis, here it may be an early sign, 
localized over the affected apex. 



METHODS OF PHYSICAL DIAGNOSIS. 87 

Cause of cog-wheel breathing : in some cases 
(pain and nervousness) it may be due to the 
irregular and undecided manner of respira- 
tion, in others (phthisis) it is probably caused 
by the break or delays in the passage of air 
through the affected bronchioles. It would 
seem to be due in some cases, where ob- 
tained in the neighborhood of the heart, to 
the impulse of that organ against the lung 
forcing the air out, as the wavy interruptions 
are synchronous with the cardiac systole. 
In fibrosis of the left lung the systolic wavy 
interruption of respiration, particularly of 
inspiration, may be due to the forcing of 
blood through contracted arterioles, as sug- 
gested by I. N. Hall, Jour. Am. Med. Assoc. , 
July 17, 1897. 
Character : either the inspiratory or expira- 
tory sound, or both, may be broken into 
several parts, or may be characterized by 
successive variations in intensity ; usually 
it is most marked in inspiration. 
Interval between Inspiration and Expiration 
may be more or less prolonged. 
In emphysema, owing to a deferred expira- 
tory sound. 
In consolidation of the lung owing to short- 
ening of the inspiratory sound. 
Shortened Inspiratory Sound. 

Locality (where and when heard) and Cause. 
In emphysema it is due to the beginning of 

the respiratory act before the beginning 

of the sound. 
In consolidation (bronchial breathing) it is 

due to the ending of the inspiratory sound 

before the ending of the inspiratory act. 



88 PHYSICAL DIAGNOSIS OF THE CHEST. 

Character. 

When due to emphysema. 
Quality, vesicular. 
Pitch, comparatively low. 
When due to consolidation. 
Quality, tubular. 
Pitch, high. 
Prolonged Expiratory Sound. 
Locality. 

Normal, over the right apex ; sometimes pro- 
longed expiratory sound over the left apex 
in slightly less degree ; over the larynx, 
trachea, and bronchi (vide the landmarks). 
Abnormal, over consolidated lung; over a 
cavity ; over emphysematous lung ; in 
asthma ; in case of certain valve-like ob- 
stacles in the air-passages. 
Cause : difficult and prolonged exit of air 
from the lungs — e. g., in emphysema, owing 
to loss of elasticity of the lung ; in asthma, 
owing to spasm of the bronchial muscles. 
Character. 

When due to solidification of the lung. 
Quality, tubular. 
Pitch, high. 
When due to a cavity. 
Quality, blowing, cavernous or amphoric. 
Pitch, low. 
When due to emphysema. 
Quality, vesicular. 
Pitch, low. 
When due to asthma. 
Both quality and pitch are obscured by 
dry rales. 
VOCAL SOUNDS. 

Elements of Sound : these are like those consid- 



METHODS OF PHYSICAL DIAGNOSIS. 89 

ered in respiration and percussion, though not 
all of them are so significant in the consideration 
of vocal sound. 
Varieties of Vocal Sound. 
Normal (Vesicular) Vocal Resonance. 
Locality, it is heard 

Over the lung at a distance from the trachea 

and bronchi while the person is speaking. 

In adult males it is generally heard over the 

entire lung. 
In women and children it is heard over the 
upper part of the chest, and but indis- 
tinctly over the lower part. 
Cause : it is due to the transmission of the 
voice through the parenchyma of the lung 
and the chest- wall. 
Character. 

Quality , diffused, muffled, buzzing, seeming 
to come from the deep parts of the lung 
(articulation not transmitted). 
Pitch, varies with the pitch of the voice. 
Intensity, greater over the right apex than 
over the left, especially in the infra-clav- 
icular region. 
Variations from the normal are chiefly in 
intensity. 
Diminished vocal resonance. 

Locality and cause : it is the result largely 
of those conditions which cause feeble 
respiratory sounds. 
Exaggerated vocal resonance. 

Locality : it is heard over moderately con- 
solidated lung ; pneumonia, phthisis, etc. 
Cause, consolidated lung is a better me- 
dium for transmitting sound from the 
larynx than is ordinary lung tissue. 



90 PHYSICAL DIAGNOSIS OF THE CHEST. 

Character : it differs from normal vocal 
resonance simply in being more intense, 
seeming to come from a point not far 
distant from the surface. It is usually 
associated with broncho-vesicular respi- 
ration. 
Bronchophony or Bronchial Voice. 
Locality. 

Normal, heard over the main bronchi. 
Abnormal, heard. 

Over consolidated lung as in the second 
stage of pneumonia, phthisis ; above the 
level of the fluid in pleuritic effusion. 
Over a vomica with firm walls (some- 
times), surrounded by consolidation. 
Cause, consolidated lung a better medium of 

transmission. 
Character. It is more concentrated than nor- 
mal vocal resonance and exaggerated vocal 
resonance, seeming to come from a point 
near the ear, immediately under the steth- 
oscope (no distinct articulation). It is usually 
associated with bronchial breathing, though 
not necessarily. Its pitch varies, and its in- 
tensity also, though usually increased above 
that of normal resonance. 
Varieties of Bronchophony. 
JEgophony (goat voice). 

Locality, over consolidated lung, covered 
by a thin layer of fluid in the pleural 
cavity, as in pleuro-pneumonia with 
slight pleuritic effusion. 
Character, it is like that of bronchophony, 
except that it is of less intensity and 
has a tremulous sound, seeming to come 
from a considerable depth. 



METHODS OF PHYSICAL DIAGNOSIS. 91 

Pectoriloquy (speaking through the chest). 
Locality and cause. It is heard 

1. Over consolidated lung, phthisis, 

pneumonia. 

(a) Quality, clanging, metallic. 

(b) Pitch, high. 

2. Over a cavity with smooth walls and 

a large opening, abscess, bron- 
chiectasis, etc. 
(a) Quality, soft. 
(6) Pitch, low. 
Character, it is like that of bronchophony 
with the addition of distinct articula- 
tion in the transmitted voice. 
Amphoric Voice. 

Locality, over pneumo-thorax or pulmonary 

cavity with a free opening. 
Character. 

Quality, hollow, musical. 
Pitch and Intensity, variable. It is fre- 
quently associated with amphoric respira- 
tion and resonance. 
WHISPERING SOUNDS. 

Normal Whispering Resonance. 
Exaggerated Whispering Resonance. 
Whispering bronchophony. 
Cavernous Whisper. 
Whispering Pectoriloquy. 
Amphoric Whisper. 

These whispering sounds correspond largely in 
locality, cause and character to the vocal sounds, 
the sound of phonation being substituted by that 
of aspiration. 
TUSSIVE OR COUGH SOUNDS. Cough though a 
symptom is a sign of importance. 
Definition. A deep inspiration is followed by 



92 PHYSICAL DIAGNOSIS OF THE CHEST. 

closure of the glottis, contraction of the mus- 
cles of expiration, rise of tension within the 
pulmonary air-passages, and sudden opening of 
the glottis with violent explosive escape of the 
compressed air and fibration of the vocal cords. 
Relation to Auscultation. Much the same laws 
govern the sounds produced by coughing as 
apply to vocal sounds in auscultation of the 
chest. 
Cough may Remove Temporary Obstacles 

from the air-passages, thereby changing or 

destroying sounds. 
It Necessitates Subsequent Deep Inspiration 

with consequent distention of the air- vesicles. 
Varieties of Cough. It is dry or moist according 
to the amount and character of the accompany- 
ing secretion. 
Laryngeal Cough, hacking, often spasmodic, 

and due to laryngitis, local irritation, or to 

reflex nervous trouble. 
Bronchial Cough, dry or tight, quick, harsh, 

and brassy. Loose, more or less rattling, 

owing to secretion within the tubes. It is 

frequently accompanied by pain along the 

attachments of the diaphragm, and more or 

less soreness under the sternum. Bronchitis. 
Cavernous Cough has a hollow quality, and is 

usually intense and accompanied by gurgling 

sounds. 
Amphoric Cough is ringing, with the peculiar 

resonance heard in blowing across the neck of 

a bottle. 

The terms cavernous and amphoric cough 
refer to sounds heard upon auscultation 
in certain cases where cavities open into 
large bronchi. 



METHODS OF PHYSICAL DIAGNOSIS. 93 

Causes of Cough. It may be 

Voluntary, or may be 

Involuntary, due to stimulation of the 

Nerve centre in the floor of the fourth ven- 
tricle. 
Reflex. 

Nerve-trunks. 

Vagus or superior laryngeal nerves. 
Peripheral. 

Direct stimulation of the mucous mem- 
brane of the air-passages by irritat- 
ing particles, cold air, etc. Espe- 
cially the surface of the 
Soft palate and pharynx. The 
Larynx is the most sensitive part of the 

air-passages. 
Trachea and bronchi : the most sensi- 
tive part is at the bifurcation of the 
trachea. 
Indirect stimulation. 

Irritation of the pleura (the costal layer) 

as in pleurisy. 
Irritation of the auditory meatus. 
Decayed teeth. 
Irritation of the post nares. 
Irritation of the shin by cold draughts. 
Derangement of the stomach possibly a 
cause of cough. 
ADVENTITIOUS SOUNDS. 
Males. 

Moist Rales. 

Large, coarse, or mucous rales. 

Locality, where produced : large and middle- 
sized tubes ; " death rattle " heard in the 
trachea. 
Cause, air bubbling through fluid, whether 
mucus, blood, or pus. 



94 PHYSICAL DIAGNOSIS OF THE CHEST. 

Character. 

Quality, bubbling, moist. 
Pitch, usually low but variable. 
Intensity, variable. 

Duration, they may be removed by cough- 
ing or deep inspiration. 
Rhythm, they may accompany inspiration, 
expiration, or both. 
Condition, acute and chronic bronchitis, pro- 
fuse pulmonary hemorrhage, etc. 
Small, fine, mucous, or subcrepitant r&les. 
Locality, small tubes. 
Cause, air bubbling through fluid. 
Character. 
Quality, moist, fine, bubbling, or crack- 
ling or sticky (mixed in size). 
Pitch, varying with size of tube and con- 
dition of surrounding lung. 
Intensity, variable. 
Duration, they may be removed by deep 

inspiration or cough. 
Rhythm, they may accompany either or 
both acts of respiration. 
Condition, capillary bronchitis, third stage 
of tuberculosis, lobular pneumonia, pul- 
monary congestion and oedema, severe 
hemorrhage, chronic bronchitis, etc. 
Dry Rales. 

Sonorous Rales. 
Locality, large tubes. 

Cause, narrowing of the lumen of the 
bronchi, from viscid mucus adhering to 
their wall ; swelling of the mucous mem- 
brane ; spasm of the annular bronchial 
muscles ; fibroid contractions ; pressure 
upon the bronchi by an aneurysm or other 
tumors or swellings. 



METHODS OF PHYSICAL DIAGNOSIS. 95 

Character. 
Quality, snoring. 
Pitch, low. 

Intensity, variable, usually very loud. 
Duration, they are usually not removable 
by cough or deep inspiration, except 
when due to viscid mucus. 
Rhythm, they may accompany either or 
both acts of respiration. 
Conditions, asthma, bronchitis, and other 
more rare conditions causing narrowing 
of the tubes. 
Sibilant RIles. 
Locality, small tubes. 
Cause, same as that of sonorous rales. 
Character. 
Quality, whistling, hissing, creaking. 
Pitch, high. 

Intensity, less than sonorous, but variable. 
Duration, they may be removed by cough 

or deep inspiration. 
Rhythm, they may accompany either or 
both acts of respiration. 
Conditions, asthma and bronchitis. 
Crepitant Rales. 

Locality, they are produced in the ultimate 

air-vesicles. 
Cause (probably), sudden separation of the 
walls of collapsed air-vesicles, adhering 
more or less, from the presence of fibrinous 
exudate upon their surfaces. 
Character. 

Quality, like the crackling of salt thrown 
upon the fire, dry, very fine, numerous, 
and uniform in size, as compared with 
subcrepitant rales, which are coarser, 



96 PHYSICAL DIAGNOSIS OF THE CHEST. 

bubbling, moist, fewer in number, and 
of different sizes. 
Pitch, high. 
Intensity, variable. 

Duration, they are not disturbed by cough. 
Rhythm, they are never heard in expira- 
tion, always in inspiration, usually at 
its end. 
Condition, typically in the first stage of 
lobar pneumonia, sometimes in incipient 
tuberculosis at the apex of a lung ; rarely 
in pulmonary hemorrhage and oedema. 
They may frequently be found at the 
lower part of the posterior aspect of the 
chest for a few deep inspirations in feeble 
persons who have been in the recumbent 
posture for some time. 
Indeterminate R£les. 

Crumpling sounds, somewhat like those of 
normal muscular contraction, are some- 
times to be heard. 
Locality. 

Normal, sometimes heard at the end 
of a forced inspiration, usually bi- 
lateral. 
Abnormal, they are sometimes heard in 
emphysema. 
Cause, none known definitely. 
Character, something like the sound of 
parchment when wrinkled, and occur- 
ring at the end of forced inspiration. 
Condition, emphysema. 
Friction Sounds. 

Locality, over inflamed pleura or pericardium, 

rarely over the peritoneum. 
Cause, rubbing together of two serous surfaces, 



METHODS OF PHYSICAL DIAGNOSIS. 97 

roughened by exudate, or dry from diminished 
secretion. 
Character. 

Quality, rasping, grating, grazing, creaking, 
simulated by rubbing the hand upon the 
chest during auscultation. They are few in 
number compared with rales, and are irreg- 
ular in occurrence. 
Duration, they are not removable by cough 

or deep inspiration. 
Rhythm, usually they are most prominent at 
the end of inspiration or beginning of ex- 
piration. 
Condition, pleurisy and pericarditis in the first 
stage ; rarely in peritonitis over the spleen or 
liver. 
Unclassified Adventitious Sounds* 
Metallic Tinkling". 
Locality. 

Normally y it may be heard at times over the 

stomach. 
Abnormally, over the pleural cavity contain- 
ing air and fluid, especially when com- 
municating with a bronchus above the 
level of the fluid. 
Cause : the dropping of fluid in a cavity con- 
taining fluid and air. 
Character. 

Quality, silvery, tinkling, or splashing. 
Pitch, high. 

Intensity, slight, but variable. 
Rhythm, either in inspiration or expiration, 
or during cough, or occasionally inde- 
pendent of them. 
Condition, pneumo-hydrothorax, pulmonary 
abscess, etc. 
7 



98 PHYSICAL DIAGNOSIS OF THE CHEST. 

Splashing" or Succussion Sound. 

Locality, same as that of metallic tinkling. 
Cause, splashing of fluid within an air-con- 
taining cavity, heard when the body is 
shaken, with the ear of the examiner against 
the surface, over the part. 
Character, splashing. 

Condition, pneumo-hydrothorax or pneumo- 
pyothorax. 
Bell Sound. 

Locality, it is heard over a large air-contain- 
ing cavity. 
Cause : with the ear against the cavity, per- 
cussion is made upon the chest at the oppo- 
site side of the cavity, two coins being used 
as plexor and plexi meter ; the sound heard 
is due to the vibration of the air within the 
cavity. 
Character, ringing, hollow, metallic. 
Condition, pneumothorax. 
Veiled Puff, so called, is a short hollow, whiff- 
ing or puffing sound sometimes high in pitch, 
which may be heard in the latter part of in- 
spiration over a small cavity, as in sacculated 
bronchiectasis. 
Post-tussive Suction Sound is a sucking, or 
sometimes semi-sonorous sound, which has 
been heard after cough, in case of cavity with 
yielding walls and an opening into a bronchus. 
It occurs with the inspiratory entrance into 
the cavity of air which has been driven out 
by compression in the act of coughing. 

sounds rnonucEn by the cimcujlatoby 

MECHANISM. 
CARDIAC SOUNDS. 

Normal Cardiac Sounds. 



METHODS OF PHYSICAL DIAGNOSIS. 99 

First Sound of the Heart. 

Cause of the first sound : it is chiefly due to 
the closure of the auriculo- ventricular valves 
(mitral and tricuspid). To a slight extent 
this sound may also be due to contraction 
of the walls of the ventricle in systole, the 
impulse of the apex against the chest-wall, 
and the rush of blood through the ven- 
tricles, (valvular) of the first sound. 
Elements of the first sound. 

Mitral element, heard best at the apex, and 
behind at the angle of the scapula. It is 
slightly louder than the tricuspid. 
Tricuspid element, heard best at the lower 
end, a little to the left, of the sternum. 
Character of the first sound. 

Quality, " lubb," dull, soft, booming. 
Pitch, lower than that of the second sound. 
Intensity, greatest at the apex beat, varying 
with the strength of the heart, the condi- 
tion of the valves and cavities, and the 
amount and kind of tissue interposed be- 
tween the heart and the listening ear. 
The heart sounds are conducted by con- 
solidated lung, and transmission is less- 
ened by emphysematous lung and thick, 
fatty chest- wall. 
Duration, long as compared with the second 
sound. In thin nervous persons the first 
sound at the apex is apt to be clear and 
ringing in quality, short in duration, and 
somewhat high in pitch, though always 
lower than the second sound. 
Rhythm, systolic, synchronous with the sys- 
tole of the ventricles, the apex beat, and 
carotid pulse ; preceded immediately by 



100 PHYSICAL DIAGNOSIS OF THE CHEST. 

the long pause, succeeded immediately by 
the short pause. 
Second Sound of the Heart. 

Cause of the second sound : it is chiefly due 
to the closure of the semilunar valves, aug- 
mented by the vibration of the neighboring 
parts. 
Elements of the second sound. 

Aortic element, heard best in the second 
intercostal space, close to the right of the 
sternum. 
Pulmonic element, heard best in the second 
intercostal space to the left of the ster- 
num ; not so loud as the aortic. 
Character of the second sound. 
Quality, "dupp," sharp. 
Pitch, higher than that of the first sound. 
Putensity, greatest at the base of the heart ; 

variable like the first sound. 
Duration, shorter than the first sound. 
Rhythm, it is preceded immediately by the 
short pause, and succeeded immediately 
by the long pause. The relation of the 
first and second sounds with the inter- 
vening pauses may be represented thus : 

"lubb," — "dubb," . 

Modifications of the Normal Heart Sounds* 
Modification of the First Sound, in 
Intensity and duration. 

Diminished intensity of the first sound, from 
Weakness of the heart as a result of — 

1. General diseases, fevers, chronic 
wasting disorders, aneurysm, etc. 

2. Local diseases of the heart : fatty 
degeneration or infiltration ; atrophy, 
amyloid, or fibroid degeneration ; 



METHODS' OF PHYSICAL DIAGNOSIS. 101 

valvular disease ; pericardiac effu- 
sion, etc. 
Interposition of tissues, as in emphysema, 
pleuritic effusion, thick chest- walls from 
fat or muscle. 
Increased intensity and duration of the first 
sound ; it may be 
Longer in duration, loud and booming, 
as in hypertrophy of the left ventricle 
from cirrhotic kidney ; aortic stenosis 
and sometimes in aortic aneurysm, or 
Shorter in duration and sharper, as in 
case of thin chest-walls, emotional ex- 
citement, physical exertion, onset of fe- 
brile disease. In pure mitral obstruc- 
tion it is often louder than normal. 
Quality : the first sound may be impure ; it 
may be sharper or duller than usual, more 
flapping or clacking. 
Rhythm. 

.Reduplication. 

Cause : non-synchronous action of the 
mitral and tricuspid valves, so that 
the maximum intensity of the left first 
sound does not coincide w r ith the right. 
Non-synchronous action of the cusps of 
either valve has been given as a cause, 
but this is not probable. 
Character, as related to the second sound ; 
it may be represented thus : " lubb," 

"lubb," — "dupp," . 

Frequency : it is not uncommon, but the 
second or diastolic sound is more fre- 
quently reduplicated than the first or 
systolic sound of the heart. 
Significance : it is usually temporary, but 



102 PHYSICAL DIAGNOSIS OF THE CHEST. 

may be permanent ; it is either physio- 
logical or pathological, and it is not 
peculiar to any particular lesion or con- 
dition. 
Irregularity may involve time or intensity, 

or both. 
Intermittency or dropping of the first sound. 
Modification of the Second Sound. 
Intensity. 

Diminished intensity of the second sound 
from 
Diminished power of the right or left 
ventricle, by which less blood is thrown 
into the aorta and pulmonary artery, 
producing less tension in them, and 
hence, less forcible recoil of their elas- 
tic walls, and less sudden and forcible 
closure of the semilunar valves. 

1. General debilitating diseases, or 

2. Local diseases impairing the 
strength of the heart or elasticity 
of the main arteries. 

Stenosis of the mitral or tricuspid orifices 
or of the orifices of the aortic or pul- 
monary artery, reducing the tension in 
those vessels. 

Lesion of the pulmonary or aortic valves 
impairing their closure. 

Lessened resistance in the peripheral cir- 
culation, by lowering the tension in the 
large arteries. 
Increased intensity or accentuation of the 
second sound. 

Pulmonic second sound may be accen- 
tuated as a result of increased tension 
in the pulmonary artery from hyper- 



METHODS OF PHYSICAL DIAGNOSIS. 103 

trophy of the right ventricle ; ob- 
structed pulmonary circulation depend- 
ent upon pulmonary disease or valvular 
disorder of the left heart. Whenever, 
under like conditions of transmission, 
the pulmonic second equals or exceeds 
in intensity the normal aortic sound it 
is accentuated. 
Aortic second sound may be accentuated 
as a result of increased tension in the 
aorta from hypertrophy of the left ven- 
tricle or obstruction in the aortic or 
general circulation : chronic renal dis- 
ease and some cases of aortic an- 
eurysm. Both first and second heart 
sounds may be so loud in exophthalmic 
goitre as to be heard by the patient, or 
others at a distance of four feet from 
the patient (Graves). 
Quality : the second sound of the heart may 
be sharper or duller, or flopping or more 
booming in character. The latter quality 
is especially marked in accentuation of the 
aortic sound. All the heart sounds may be 
metallic and hollow where there are neigh- 
boring cavities of lung or pleura. 
Rhythm. 

Reduplication of the second sound. 

Cause : non-synchronous action of the 
aortic and pulmonic valves, or possibly 
non-synchronous action of the cusps of 
either of these valves. Ceradini sup- 
poses that the aortic and pulmonic 
valves normally close together with an 
audible sound at the end of systole of 
the respective ventricles, and that this 



104 PHYSICAL DIAGNOSIS OF THE CHEST. 

is followed so quickly by the recoil of 
the respective arteries, each also pro- 
ducing a slight sound, that the sounds 
of the valve closure and arterial recoil 
are synchronous, forming the ordinary 
seconds. A variation of tension in 
either artery may produce separation 
of these two elements, the valvular 
and arterial, thus producing reduplica- 
tion either of the pulmonic or aortic 
sound. 
Character, as related to the first sound 
it may be represented thus : " lubb," 

— "dupp," "dupp," . 

Frequency and significance (vide redupli- 
cation of the first sound). 
It is occasionally heard even in health in 
conditions favoring pulmonary conges- 
tion, such as violent exertion. It may 
sometimes be heard at the end of a full 
inspiration. 
It is common in mitral stenosis, where 
such congestion is permanent. 
Irregularity and 

Intermitteney of the second sound (vide first 
sound of the heart). 
Abnormal Cardiac Sounds or Murmurs. 
Exocardial Murmurs. 

Pericardiac friction sounds. 

Locality, over the prsecordium, usually best 
heard over the base of the heart, or over 
the junction of the left fourth costal car- 
tilage with the sternum. Their maxi- 
mum intensity is not usually at one of 
the valve areas, and they are apt to 
radiate equally about the points of greatest 



METHODS OF PHYSICAL DIAGNOSIS. 



105 



intensity, but are limited to the pre- 
cordium. 

Cause, inflammation of the pericardium 
causing roughness and dryness of the 
membrane in the first and at the end 
of the third stage. 

Usual accompanying symptoms and signs, not 
those of mechanical disturbance of circu- 
lation, as in valve lesions. 



svc 



RA 




Fig. 8.— Normal blood-currents in the heart and relative position of the ventri- 
cles, auricles, and great vessels. IVC, inferior vena cava; SVC, superior vena 
cava ; RA, right auricle : TV, tricuspid valves ; RV, right ventricle ; P, pulmonary- 
valves ; PA, pulmonary artery ; Pv, pulmonary veins ; LA, left auricle ; MV, mitral 
valves ; LV, left ventricle ; A, aortic valves ; Aa, arch of aorta. (From Page.) 



Character. 

Quality, rubbing, grating, rasping, creak- 
ing^ 

Intensity, variable, increased by forced 
expiration, by pressure of the steth- 
oscope, and by forward inclination of 



106 PHYSICAL DIAGNOSIS OF THE CHEST. 

the patient. They seem to be more 
superficial than endocardial murmurs. 
Rhythm, independent of respiration and 
synchronous with systole or diastole, 
or both. 
Pericardiac splashing and churning 
sounds have been heard occasionally in 
cases of sero- or pyo-pneumo-pericardium. 
Pleuro-pericardiac friction sounds similar 
in character to pleuritic friction sounds, but 
produced by the motion of the heart in sys- 
tole, causing to-and-fro rubbing of the in- 
flamed pleura. The pleura alone, or both 
the pleura and pericardium, may be in- 
volved in the inflammation. 
Pneumo-pericardiac or cardio-pulmonary 
sounds are soft blowing murmurs of rare 
occurrence, produced by the motion of the 
heart in forcing air from an adjacent pul- 
monary cavity, the air supposedly being ex- 
pelled from the cavity in systole and return- 
ing during diastole. 
Endocardial Murmurs include organic and in- 
organic. 
Organic endocardial murmurs include val- 
vular and non-valvular. 
Valvular, organic, endocardial murmurs in- 
clude systolic and diastolic. 
Systolic, organic, valvular murmurs in- 
clude those of the right and those 
of the left heart. 
1. Of the left heart. 

(a) Mitral systolic, indirect, or re- 
gurgitant murmurs. 
Cause : insufficiency of the mitral 
valve from 



METHODS OF PHYSICAL DIAGNOSIS. 



107 



Time 



rime ( Direct f Aortic 

of < (Obstructive). 1 Pulmonic 
rmurs. i T j- f Mitral. 

1^ lL S!!?_.^i Tricuspid 



{Direct 
(Obst 
T J- _i 



murmurs. 



^r 



aun : ulo^mcul a MaK-. ' ■ 



Tearing or perforation of a cusp. 

Inflammatory retraction of the 
cusps. 

Rigidity of the cusps. 

Vegetations, preventing closure. 

Rupture or shortening of the 
chordae tendineae. 

Dilatation of the left ventricle 
without compensatory length- 
ening of the chordae. 



Diastole of ventricles, 




Diastole of auricles. 



Indirect 

(Regurgitant). 



U- Systole of auricles. 
Time f Mitral, 

of I Direct 

murmurs. (Obstructive). 

(Presystolic.) (^Tricuspid. 
Direct 
(Obstructive). 



Fig. 9.— Diagram showing trie time of valvular murmurs in the cardiac cycle. 
The cardiac cycle is divided into tenths. The first sound occupies four-tenths ; the 
short interval, or silence between first and second sounds, occupies one-tenth; the 
second sound occupies two-tenths ; the long interval following second sound occu- 
pies three-tenths ; the systole of the ventricles occupies the time of the first sound 
and the short interval. 

Relation of murmurs to the heart-sound : murmurs may precede, occur with, or 
take the place of the heart-sounds. Their time is, in a general way, indicated in 
the diagram by arrows. 

Spasm of the columnae carneae. 
Usual accompanying symptoms 
and signs : 

Pulse, compressible and more or 
less irregular. 

Indications of pulmonary, he- 
patic, and renal congestion 



108 PHYSICAL DIAGNOSIS OF THE CHEST. 

with oedema of the feet and 
ankles are common in cases 
of non-compensation. 
Enlargement of the left heart, 
with especial increase in trans- 
verse diameter. 
Pulmonic second sound accen- 
tuated. 
Character of the murmur of mitral 
regurgitation : 
Quality, apt to be blowing and 

soft. 
Rhythm, systolic, accompany- 
ing, or replacing, the first 
sound of the heart at the 
apex. 
Intensity, varies in different 
cases, but the loudness of a 
murmur is not proportionate 
to, and does not indicate the 
severity of the lesions causing 
it. This is equally true of 
all organic murmurs. 
Area of maximum intensity is at 

the apex. 
Propagation of the murmur is fre- 
quently to the left of the apex ; 
it is often heard at the lower 
angle of the scapula, but is not 
usually heard at the base of the 
heart, and is never transmitted 
into the carotids. The trans- 
mission of murmurs to the left 
of the apex depends upon the 
following factors : 
Time : whether or not it occurs 



METHODS OF PHYSICAL DIAGNOSIS. 109 

when the apex of the heart 
strikes the chest- wall (systole). 

Enlargement of the heart. 

Position of the heart relative to 
the transverse diameter of the 
chest-cavity. 

Condition of the left lung. 

Thickness of the chest-wall. 

Intensity of the murmur. 
Frequency of the murmur of mitral 

regurgitation, it is the most fre- 
quent of all valvular murmurs. 
(6) Aortic systolic, direct murmur. 
Cause : 

Obstruction at the orifice, 
guarded by the aortic semi- 
lunar valve due to thickening 
and rigidity of the cusps from 
fibroid, calcareous, or athero- 
matous change ; vegetations ; 
adhesion of the cusps ; indu- 
ration and contraction of the 
fibrous ring or margin of the 
aortic opening ; congenital 
malformation (rare). 

Simple roughening of the cusps. 

Simple stenosis at the aortic ring 
is a relatively rare affection. 
A vast majority of the systolic 
aortic murmurs are due to the 
other causes mentioned. 

Marked dilatation of the aorta 
immediately beyond the val- 
vular opening, the latter re- 
maining relatively normal in 
size. 



110 PHYSICAL DIAGNOSIS OF THE CHEST. 

Usual accompanying symptoms 
and signs in cases of marked 
obstruction : 
Pulse tardy and small, but reg- 
ular unless the heart be 
greatly embarrassed. It is 
apt to be hard and wiry. 
Thrill or fremitus often felt over 
the base of the heart, espe- 
cially over the aortic area. 
Evidence of cerebral anaemia 

not uncommon ; 
Enlargement of the left heart ; 
Pulmonic second sound, feeble ; 

and 
Aortic second sound, feeble or 
inaudible. 
Character of the aortic direct mur- 
mur : 
Quality, usually harsh when due 
to stenosis or marked obstruc- 
tion, otherwise it is apt to be 
soft. It is sometimes musical. 
Rhythm systolic, with the first 
sound. 
Area of maximum intensity or 
seat : the right second inter- 
costal space close to the ster- 
num, sometimes over the left 
interspace or over the upper 
part of the sternum at the same 
level. 
Propagation, into the arteries of 
the neck and down the sternum, 
and toward the apex, but with 
diminished intensity. It is also 



METHODS OF PHYSICAL DIAGNOSIS. Ill 

frequently heard when loud, be- 
hind to the left of the fourth 
dorsal vertebra, but is not usually 
transmitted to the left of the 
apex. 
2. Of the right heart (systolic, organic, 
valvular murmurs), 
(a) Tricuspid systolic, indirect or re- 
gurgitant murmur. 
Causes may be similar to those of 
mitral regurgitant murmur, but 
usually it results from relative 
incompetency of the valve in 
dilatation of the right ventricle, 
secondary to diseases of the 
lungs or serious lesions of the 
left heart. 
Usual accompanying symptoms 
and signs : Commonly pulmon- 
ary diseases or lesions of the left 
precede those of the right heart ; 
the associated manifestations are 
often those of 

Congestion of the brain and 
abdominal organs; pulsa- 
tion of the 
Jugular and sometimes of the 
Hepatic veins. 

Enlargement of the right 
heart and usually of the 
left. 
Pulmonic second sound,feeble. 
Character of the murmur of tri- 
cuspid regurgitation : 
Quality, blowing. 
Rhythm, systolic, with or re- 



112 PHYSICAL DIAGNOSIS OF THE CHEST. 

placing the first sound of 
the heart. 
Area of maximum intensity, the 
tricuspid area at the end of and 
along the left side of the sternum : 
Propagation very limited ; if any- 
where, it is transmitted to the 
right, sometimes even to the 
axilla. It is not heard at the 
apex or behind or over the ca- 
rotids, and is seldom audible 
above the third rib. 
Frequency : it is comparatively 
rare, and very uncommon, from 
primary lesion of the tricuspid 
valve. 
(b) Pulmonic, systolic, direct mur- 
mur. 
Cause : usually obstruction from 
conditions somewhat similar to 
those affecting the aortic orifice ; 
rarely are lesions of this valve 
the result of rheumatism. They 
are generally congenital. 
Usual accompanying symptoms 
and signs : 
Enlargement of the right heart ; 
Evidence of venous engorge- 
ment ; 
Bruit de diable occasionally 

heard over the jugulars. 
Pulmonic second sound weak. 
Character of the murmur of pul- 
monic obstruction : 
Quality, variable, apt to be 
harsh. 



METHODS OF PHYSICAL DIAGNOSIS. 113 

Khythm, systolic, accompanying 
the first sound. 
Area of maximum intensity : in 
the left second intercostal space 
close to the sternum. 
Propagation occasionally toward 
the left shoulder, never toward 
the apex nor along the aorta. 
It is not heard over the lower 
part of the sternum, nor be- 
hind. 
Frequency : very rare. 
Diastolic, organic, valvular murmurs. 
1. Of the left heart. 

(a) Mitral diastolic (presystolic), di- 
rect murmur. 
Cause : obstruction of the mitral 
opening. This murmur may 
possibly occur, according to 
Flint, without mitral lesion, 
where there is aortic regurgita- 
tion with marked dilatation of 
the left ventricle. 
Usual accompanying symptoms 
and signs : 
Pulse, in marked cases, small. 
Purring thrill or fremitus, pre- 
systolic and most distinct at 
the apex, not uncommon. 
Diastolic shock is common over 
the base of the heart to the 
left of the sternum, most in- 
tense in the second interspace 
near the sternum. It is due 
to forcible closure of the pul- 
monic valves, the sound of 



114 PHYSICAL DIAGNOSIS OF THE CHEST. 

which is in such cases greatly 
accentuated. 

Evidence of pulmonary engorge- 
ment. 

Enlargement of the left auricle. 

Pulmonic second sound accen- 
tuated. 

Mitral first sound is apt to be 
sharp unless a regurgitation 
coexists. It terminates the 
presystolic murmur. 
Character of the murmur of mitral 
stenosis : 

Quality, harsh, churning, grind- 
ing, blubbering. It is repre- 
sented by vocalizing the sym- 
bols rrrb or voot, the b and t 
representing the sharp first 
sound terminating the mur- 
mur. 

Duration, it is apt to be longer 
than other murmurs. 

Rhythm, diastolic (presystolic), 
probably occurring in auricu- 
lar systole. 

Area of maximum intensity : at 
the apex beat or half an inch 
above it. Usually louder when 
the patient is erect. 

Propagation limited : not trans- 
mitted to the left of the apex, 
nor into the arteries of the 
neck, nor is it heard behind. 

Frequency : common. 
(b) Aortic, diastolic, indirect, regurg- 
itant murmur. 



METHODS OF PHYSICAL DIAGNOSIS. 115 

Cause : insufficiency of the valve 
from much the same causes as 
those producing mitral insuffi- 
ciency, except those referring to 
the chordae tendinese. 
Usual accompanying symptoms 
and signs : 
Pulse full, strong, and collapsing 
in diastole; forcible beating 
of the 
Carotids. 
Capillary pulsation in marked 

cases. 
Enlargement of the left heart, 
with perhaps secondary en- 
largement of the right. 
Character of the murmur of aortic 
regurgitation : 
Quality, soft, blowing, rushing, 

and occasionally musical. 
Rhythm, diastolic, accompany- 
ing, or replacing, or imme- 
diately following the second 
sound of the heart. 
Area of maximum intensity : in 
the right second interspace, or 
over the sternum at the level of 
the second costal cartilage, fre- 
quently in the left, second in- 
terspace, and sometimes at the 
xiphoid cartilage. 

Occasionally it has its seat at the apex, 
when it is thought by Foster to indicate 
lesion of the left posterior cusp. 

Propagation : down the sternum 
to the epigastrium ; to the apex, 



116 PHYSICAL DIAGNOSIS OF THE CHEST. 

where it is sometimes very loud 
and conveyed to the left ; to the 
arch of the aorta and into the 
carotids ; and behind, along the 
right side of the spinal column. 
It may be heard occasionally 
even in the radial and femoral 
arteries. The area of diffusion 
is greater than that of any other 
murmur. 

Frequency : it stands third in order 
of frequency. 
2. Of the right heart. 

(a) Tricuspid, diastolic (presystolic), 
direct murmur. 

Cause : obstruction at the tricuspid 
opening (vide aortic and mitral 
stenosis). 

Usual accompanying symptoms 
and signs : those of systemic 
venous engorgement, notably 
oedema and persistent cyanosis. 
Sometimes enlargement of the 
right auricle may be made out. 
Sometimes there is a fremitus 
to be felt over the right heart. 

The tricuspid first sound, if not 
obscured by a systolic murmur, 
may be sharp, short, and loud. 

The pulmonic second sound is feeble. 

Character of the murmur of tri- 
cuspid obstruction : 
Quality, harsh. 
Rhythm, presystolic. 

Area of maximum intensity : over 
the lower two-thirds of the 



METHODS OF PHYSICAL DIAGNOSIS. 117 

sternum, or over the right fifth 
and sixth costal cartilages. 
Propagation : may be toward the 
base faintly, but never toward 
the apex ; it is not heard above 
the base. 
Frequency : extremely rare. 
(b) Pulmonic, diastolic, indirect, re- 
gurgitant murmur. 
Cause : insufficiency of the pul- 
monic valve, usually following 
pulmonary diseases or serious 
lesions of the left heart. 
Usual accompanying symptoms 
and signs are those of the ante- 
cedent lesion ; evidence of venous 
engorgement ; enlargement of 
the right heart. 
Character of the murmur of pul- 
monic regurgitation : 
Quality, soft, blowing. 
Rhythm, diastolic, accompany- 
ing or replacing the second 
sound. 
Area of maximum intensity : over 
the left, second intercostal space. 
Propagation : downward toward 

the xiphoid cartilage. 
Frequency : rare. 
Non-valvular, organic murmur. 

Intra-ventricular or intra-auricular mur- 
murs. 
Cause : roughening of the endocardial 
lining in acute endocarditis ; rarely 
it may be due to a tendinous cord 
stretched across the ventricle (con- 



118 PHYSICAL DIAGNOSIS OF THE CHEST. 

genital) ; or cardiac aneurysm ; or an 

abnormal congenital opening between 

the two cavities, patulous foramen 

ovale. 

Usual accompanying symptoms and 
signs : none constant, though they 
may be those of acute endocarditis. 
In case of abnormal openings, per- 
sistent cyanosis is a prominent sign. 

Character of the organic, intra-ven- 
tricular murmur : 
Quality, variable, usually soft. 
Rhythm, systolic. 

Area of maximum intensity at or 
near the apex. 

Propagation : limited. 

Frequency : quite common in acute 
endocarditis. 

INORGANIC, OR FUNCTIONAL, ENDOCARDIAL 
MURMURS. 

Inorganic valvular murmurs. 

Systolic, inorganic, valvular murmurs. 
1. Of the left heart. 

(a) Mitral, systolic, inorganic, re- 
gurgitant murmur. 
May occur purely from functional 
incompetence without actual 
lesion of the valve. Its charac- 
ter does not differ from the or- 
ganic murmur. Such a murmur 
may appear and disappear with- 
out previous, accompanying, or 
subsequent evidence of endo- 
carditis. 
Frequency : it is comparatively 
rare. 



METHODS OF PHYSICAL DIAGNOSIS. 119 

(b) Aortic, systolic, inorganic mur- 
murs. 
Cause : anaemia. 

Accompanying symptoms and 
signs, those of 
Anaemia : pallor, lassitude, weak 

pulse, 
Venous hum over the jugulars, 

and frequently an 
Arterial, systolic murmur, pro- 
duced in the carotids which 
is usually of different quality 
and pitch from the cardiac 
murmur. 
No cardiac enlargement is present 
or other sign of valvular lesion. 
Character : 
Quality, soft. 
Rhythm, systolic. 
Area of maximum intensity : over 
the base of the heart, above the 
third rib, frequently in the aortic 
area. 
Propagation occurs into the arch 
of the aorta and the carotids ; 
frequently a louder murmur pro- 
duced in, and heard over the 
carotids, may accompany it. 
Frequency : the inorganic, aortic, 
systolic murmur is more com- 
mon than the organic. 
2. Of the right heart. 

(a) Tricuspid, inorganic, regurgitant 
murmur. 
Cause : functional incompetence 
of the tricuspid valve, similar 
to that of the mitral valve. 



120 PHYSICAL DIAGNOSIS OF THE CHEST. 

(b) Pulmonic, systolic, inorganic mur- 
mur. 

Cause : anaemia. 

Character: similar to that of the 
aortic, systolic, inorganic mur- 
mur. 

Area of maximum intensity is over 
the pulmonary area. 

Balfour considers that this murmur has 
its maximum intensity in the second 
interspace, a couple of inches to the 
left over the left auricular appendix, 
and therefore that it is a murmur of 
mitral regurgitation heard in the au- 
ricular area. 

Propagation is limited : it is not 
transmitted above the base of 
the heart, but may be accom- 
panied by an anaemic murmur 
produced in the carotids, which 
is frequently of different quality 
and pitch. 
Diastolic, inorganic murmur of both left 
and right heart are very rare and prac- 
tically unimportant. 
Inorganic, non-valvular murmurs are in- 
definite and unimportant. 
VASCULAR SOUNDS, sounds heard over the vessels. 
Arterial Sounds. 

Normal Arterial Sounds. 

Diastolic second sound of the heart 
may be transmitted into the aorta and 
carotids. (It may be impure or entirely 
wanting.) 
Over the aorta and commonly over the 
carotid and subclavian arteries is to be 



METHODS OF PHYSICAL DIAGNOSIS. 121 

heard a systolic rushing sound, or even de- 
cided click, which is increased by pressure 
of the stethoscope. Further pressure, with 
strong ventricular action, is apt to produce 
a short, snappy systolic murmur, produced 
by the blood pulsating through the artery 
past the obstruction. 

Over the Subclavian arteries at the end 
of inspiration a systolic, blowing murmur 
may be frequently heard in health. 

Over the abdominal aorta and crural 
arteries is sometimes to be heard a pulsating 
sound, corresponding in rhythm to the pulse 
in those arteries. 

Oyer the small vessels nothing is to be 
heard. 

Pressure of the stethoscope over any of 
the large arteries may produce a murmur 
occurring with the local pulsation. 

Over the anterior fontanelle and some- 
times over the carotids of children, between 
the ages of three months and six years, 
a blowing, systolic murmur, of variable 
intensity, is frequently heard, " cerebral 
blowing." 

Over the uterus in the latter months of 
pregnancy, uterine souffle, from entrance of 
blood into the dilated arteries of the uterus. 
Abnormal Arterial Sounds. 

Over the aorta, carotid, and subclavian 
arteries may be heard systolic and diastolic 
murmurs produced at the aortic orifice of 
the heart ; in aneurysm of these vessels a 
systolic whizzing or blowing murmur may 
be heard over them, rarely a diastolic mur- 
mur in aortic aneurysm. 



122 PHYSICAL DIAGNOSIS OF THE CHEST. 

Over the crural, brachial, radial, and 
ulnar arteries, and even the peroneal 
and dorsalis pedis, a murmur may be heard 
with the pulse in the respective vessels in 
some cases of aortic insufficiency when 
moderate pressure is made with the stetho- 
scope. 

Over the crural arteries a systolic mur- 
mur may sometimes be heard in anaemia and 
chlorosis and in high fever (as well as occa- 
sionally in health). 

Over the crural arteries a double mur- 
mur, diastolic and systolic, may be heard in 
some cases of aortic insufficiency (Traube), 

Over the crural arteries, also, in many 
cases of aortic insufficiency, a double mur- 
mur may be produced by the pressure of the 
stethoscope over the artery, "Duroziez's 
double murmur." This can only occur with 
a large, quick pulse and free regurgitation. 

Over the subclavian artery a systolic 
murmur (sometimes normal, as when due to 
pressure of the stethoscope) may be pro- 
duced by pressure of tumors on the vessel ; 
traction by lung in fibroid disease of the 
apex. 
Venous Sounds, bruit de diable. 
Normal Venous Sounds. 

Over the jugular vein, most frequently 
the right, a venous hum, whistling, or rush- 
ing sound is exceptionally heard in health, 
either continuous or rhythmically syn- 
chronous with diastole or inspiration. It 
may be produced sometimes by pressure of 
the stethoscope, or by turning the person's 
head to the opposite side. 



METHODS OF PHYSICAL DIAGNOSIS. 123 

Over the crural vein, occasionally in 
health, especially in thin persons, a sound 
may be heard, produced by sudden strain- 
ing efforts or coughing (Friedreich). 
Abnormal Venous Sounds. 
Over the jugular vein. 

In tricuspid insufficiency a systolic murmur 

may sometimes be heard. 
In anaemia and chlorosis a venous hum more 
or less continuous is often present over 
this vessel, associated with a systolic, 
blowing murmur in the carotids. It is 
less common in advanced age. Venous 
murmurs arising in the cervical veins and 
in the intrathoracic venous trunks may 
exceptionally be conducted to the heart, 
simulating valvular murmurs. 
Cause uncertain, but probably the ana- 
tomic relations have something to do 
with the murmur produced in the right 
internal jugular. This vessel is slightly 
bent at the transverse process of the sixth 
cervical vertebra, and is crossed by the 
omo-hyoid muscle. Below this it is 
surrounded by loose cellular tissue, 
and is larger in caliber. The audible 
vibrations produced are favored no 
doubt by the passage of the blood 
from the narrow to the broader part 
of the vessel forming the jugular bulb 
at its junction with the subclavian 
vein. 
Character of venous hum, bruit de 
diable. 

Quality : whizzing, rushing, or hum- 
ming (like a singing top or the sound 



124 PHYSICAL DIAGNOSIS OF THE CHEST. 

of the wind about a chimney). Some- 
times it is harsh and roaring, or there 
may be apparently a mixture of sev- 
eral tones : 
Duration and rhythm : constant but 
not uniform. It may be intermit- 
tent, varying with the pressure of 
the surrounding parts, stethoscope, 
etc. 
Intensity : loudest over the right jug- 
ular, with the patient erect and the 
head turned to the left. The in- 
tensity is increased during ventricu- 
lar diastole, during inspiration, by 
moderate pressure of the stethoscope, 
and by quickening of the circula- 
tion. 
Over the crural veins, exceptionally, in 
tricuspid insufficiency may be heard a double 
sound, indicating first auricular, then ven- 
tricular contraction. Friedreich believes 
them due to sudden sharp closure of the 
venous valves. There may be only a single 
sound due to ventricular contraction. These 
disappear when congestion is sufficient to 
destroy the competency of the valves. 

AUSCULTATORY PERCUSSION. 
This procedure, as first practised by Dr. Caman of New 
York, consists of applying the stethoscope to the chest as in 
ordinary auscultation and practising percussion in its neigh- 
borhood. The latter may be done by an assistant, or by the 
auscultator, with the aid of Ingal's emballometer. Very 
delicate distinctions of sound may be made out by this 
method, which makes it useful in some obscure cases of 
aneurysm, tumors, etc. 



SIGNS IN THE DISEASES OF THE CHEST. 125 

SUCCUSSION. 
The succussion or splashing sound is produced in a cavity 
which contains both fluid and gas, by shaking the patient. 
Normally, it may sometimes be heard over the stomach ; 
pathologically, it is a sign of pneumo-hydrothorax. The 
character of the sound is like that produced when a small 
keg, partly filled with liquid, is shaken (mfe p. 98). 

PHONOMETKY. 

The tuning-fork may aid in the detection of changes which 
have affected intrathoracic organs. If it be vibrated and 
placed over normal lung, its sound is accentuated ; if over 
airless parts, its sound is attenuated. 

THOKACENTES1S. 
Aspiration of fluid from a cavity through the chest- wall 
by means of an aspirator or hypodermic syringe, as first 
practised by Trousseau of Paris in 1835, and later in America 
by Dr. Bowditch of Boston, is of great diagnostic value in 
determining the presence or absence of suspected fluid and 
its character, histologically and bacteriologically. It should 
be done only under the strictest aseptic conditions, and with 
due regard to anatomic relations. 



PHYSICAL SIGNS IN THE DISEASES OF THE 

CHEST. 

Note. — A clear understanding of the morbid anatomy of 
a disease is essential to an appreciation of its physical signs. 
In the following synopsis, therefore, each disease, with a few 
exceptions, is introduced by a definition epitomizing its gross 
pathology. In the enumeration of the signs discovered by 
the several methods of objective examination the order will 



126 PHYSICAL DIAGNOSIS OF THE CHEST. 

be folio wed, as far as practicable, as indicated in the preced- 
ing pages — viz. under inspection, color, nutrition, size, form, 
posture and movements, etc. 



DISEASES OF THE CHEST-WALL. 

PLEURODYNIA AND INTERCOSTAL NEURALGIA. 
Definition. 

PLEURODYNIA is a thoracic, rheumatic myalgia. 
INTERCOSTAL NEURALGIA is a functional or 
organic affection of the intercostal nerves, chiefly 
manifested by pain and localized points of tenderness, 
and usually affecting women. 

Signs. 

INSPECTION shows 

AINOEMIA commonly present. 

RESPIRATION in severe cases shallow and more or 

less rapid as evidence of pain. 
MOVEMENTS OF THE BODY restricted to avoid 
pain, especially in pleurodynia. 
PALPATION may reveal 
IN PLEURODYNIA — 

Tenderness on pressure, more or less diffuse when 
superficial muscles are involved. 
IN INTERCOSTAL NEURALGIA — 

Tenderness in from one to three isolated points 
(Valleix's). 
Behind, near the dorsal vertebrae. 
Laterally, in one or more intercostal spaces along 

the axillary line. 
Anteriorly, in one or more intercostal spaces 
near the sternum or over the epigastrium. 
PERCUSSION shows— 

ABSENCE OF DULNESS, unless there be compli- 
cating or causative disease of the lungs, pleurae, or 
circulatory organs. 



SIGNS IN THE DISEASES OF THE CHEST. 127 

A USCUL TA TIOJST yields— 

NORMAL VESICULAR RESPI RATION, except slightly 
diminished in intensity or interrupted owing to re- 
stricted movements. 

ABSENCE OF PLEURITIC SOUNDS and of crepitant 
rales. 

SWELLINGS AND TUMORS OF THE CHEST- WALL. 

Definition : these include inflammatory and granuloma- 
tous affections and tumors. 

Signs : the varying color, size, shape, location, tenderness, 
consistence, and movability of each affection, whether 
originating from or involving bone, cartilage, or soft 
parts, are properly considered in works on general sur- 
gery. Suffice it to say here, that the usual respiratory 
and vocal sounds are to a degree obscured over them 
and vocal fremitus correspondingly enfeebled. The ab- 
sence of positive signs of intrathoracic disease is sug- 
gestive of one or the other of these affections. 

EMPHYSEMA OF THE CHEST-WALL. 

Definition : a rare affection characterized by inflation of 
the subcutaneous areolar tissue with air or other gas. It 
is usually associated, when marked, with a like involve- 
ment of the cervical and abdominal region, and it may 
extend over the entire body. 
Signs. 

INSPECTION may reveal — 
PALENESS of the surface. 

PUFFIN ESS, tending to obliterate the usual depres- 
sions and prominences. 
APEX BEAT absent. 
TAITATION reveals — 

PECULIAR SENSE OF YIELDING or softness, with 
crepitation fremitus felt by the finger tips pressed 
upon the surface. 



128 PHYSICAL DIAGNOSIS OF THE CHEST. 

A USCUL TA TION. 

CREPITANT SOUNDS, myriad, fine, and somewhat 
similar to the rales in pneumonia, heard when 
the ear or stethoscope is pressed upon the surface. 



DISEASES OF THE BKONCHI, PLEUK.E, LUNGS, AND 

MEDIASTINUM. 

ACUTE AND SUBACUTE BRONCHITIS. 

Definition : inflammation of the mucous membrane lining 
the larger and medium-sized tubes of both lungs. The 
early dryness and swelling is followed by more or less 
profuse secretion. 

Signs. 

INSPECTION reveals little abnormal except — 
RESPIRATORY MOVEMENTS slightly accelerated. 
COUGH at first dry, harsh, with scanty secretion, later 

moist (loose), rattling. 
DYSPNCEA rarely, except from retained secretion in 
the tubes, as in infants, the aged, or the enfeebled. 
PALPATION reveals — 

SURFACE TEMPERATURE and pulse slightly mod- 
ified. 
VOCAL FREMITUS normal. 

RHONCHAL FREMITUS in case of considerable secre- 
tion, especially in children, or in adults with thin 
chest-walls. 
PERCUSSION. 

RESONANCE normal. 

SLIGHT DULNESS rarely, over lower part of the 
chest, due to accumulation of bronchial secretion, 
though this may be removed by expectoration. 
AUSCVL TA TION. 

RESPIRATORY SOUNDS apt to be somewhat harsh 

over the larger tubes. 
VESICULAR MURMUR may be more or less sup- 



SIGNS IN THE DISEASES OF THE CHEST. 129 

pressed over parts of the lungs supplied by bronchi 

partially or wholly occluded by mucus. 
VOCAL RESONANCE normal. 
ADVENTITIOUS SOUNDS. 

Dry Utiles common in the first stage, slightly ob- 
scuring the vesicular murmur. 

Moist Males (large and small) may be heard bilat- 
erally in varying numbers after the first day or 
so, with the occurrence of hypersecretion. These 
are variable in intensity, location, and time, and 
are apt to disappear upon cough, and upon deep 
inspiration or forced expiration. A few dry rales 
may occur with them. 

CAPILLARY BRONCHITIS. 

Definition : inflammation extending from the larger to 

the smaller tubes (bronchiolitis). 
Signs. 

INSPECTION, in addition to the usual visible signs 
of acute bronchitis, reveals the age. 

AGE, young children or the aged. 

EXPRESSION of anxiety or distress common. 

CONGESTION and a more or less bloated appearance 
of the face sometimes seen. 

LIVIDITYof the face becomes more or less evident, 
both from want of proper oxygenation of the blood 
and its undue accumulation in the right heart, lead- 
ing to a fatal termination. 

AUE NASI dilated in the struggle for air. 

THE CHEST in a young child may be notably dis- 
tended at the anterior upper and middle part from 
acute compensatory emphysema, which disappears 
if recovery occurs. 

GENERAL RESTLESSNESS. 

DYSPNCEA, amounting sometimes to orthopnoea, and 

HYPERPNCEA, amounting to 60 or 70 respirations per 
minute in children. 
9 



130 PHYSICAL DIAGNOSIS OF THE CHEST. 

FALFATION. 

THE SURFACE IS HOT, and later may be covered 
with clammy perspiration. 

THE PULSE rapid, weak. 
FEBCUSSIOJST may obtain 

NORMAL RESONANCE, or 

EXAGGERATED RESONANCE over the upper lobes 
owing to emphysema, which compensates for occlu- 
sion of the many small bronchi with collapse of 
their terminal air-vesicles. 
AUSCULTATION, usually the signs of 

GENERAL BRONCHITIS of the larger tubes, and in 
addition 

SI B I LA NT RALES, very abundant early in the disease, 
replaced later by 

SUBCREPITANT rAles, both bilateral. 

CHRONIC BRONCHITIS. 

Definition : prolonged inflammation of the bronchial 
mucous membrane. This means derangement of secre- 
tion, thickening and irregularity of the surface, hyper- 
trophy of the muscular and fibrous coats, with final 
atrophy and fibrosis, eventuating in bronchiectasis, 
asthma, or emphysema. 
Signs : largely those of acute and subacute bronchitis. 
THE CHIEF CONTRAST is in the greater number 
of moist rales and the relatively few dry rales in the 
chronic affection. As the disease may tend to 
EMFHYSEMA, and frequently to more or less 
ASTHMA, the signs are correspondingly modified. 
THE ABSEJSCE of emaciation, pallor, tachycardia, 
hyperpnoea, and other evidences of phthisis is espe- 
cially important. 

PLASTIC BRONCHITIS. 

Definition : an acute or chronic inflammation of the bronchi, 



SIGNS IN THE DISEASES OF THE CHEST. 131 

chiefly characterized by the exudation of fibrinous mat- 
ter, with the formation of plastic casts in the smaller, 
sometimes involving the larger tubes. 
Signs : those of ordinary bronchitis, with the evidence 
of partial or complete obstruction of some of the bronchi, 
detected by the absence or diminution of the respiratory 
sounds over the affected parts and dulness over collapsed 
lung. 

BRONCHIECTASIS. 

Definition : dilatation of the bronchial tubes with more 
or less associated bronchitis, fibrosis, and emphysema. 

Signs. 

INSPECTION. 

DEPRESSION OF INTERCOSTAL SPACES and 
RIGIDITY OF THE CHEST- WALL, more or less 

marked, commonly unilateral. 
RESPIRATORY MOVEMENTS somewhat limited. 
COUGH with 

EXPECTORATION, usually very profuse, purulent, 
and offensive. At times more profuse in certain 
postures. 
PALPATION gives 

SIGNS VARYING greatly from time to time with the 
amount of secretion retained in the bronchiectatic 
cavities. 
Phonchal Fremitus may be present. 
Vocal Fremitus may be abnormally increased over 
a cavity if large, and freely communicating with 
the upper air-passages ; diminished when the com- 
munication is closed. 
PEBCUSSION. 

DULNESS usual over the affected lung; most com- 
monly over the right, middle and lower lobes. It 
is sometimes removed or diminished by free ex- 



132 PHYSICAL DIAGNOSIS OF THE CHEST. 

pectoration, or replaced by vesiculo-tympanitic, 
cracked-pot, or amphoric resonance. 
AUSCUL TA TIOJST. 

RESPIRATORY MURMURS sometimes 

Suppressed over Cavities, while respiratory sounds 

are apt to be harsh and exaggerated. 
Broncho-vesicular or Broncho-cavernous respira- 
tion may be obtained over a part after free ex- 
pectoration, where before no sounds were present. 
VOCAL AND WHISPER SOUNDS may suffer like 

changes. 
ADVENTITIOUS SOUNDS are usually present in the 
form of 

Males, moist and dry, and 

Gurgles, both of which are variable in character 
and time. 

ASTHMA. 

Definition : a neurosis of the respiratory mechanism, char- 
acterized chiefly by paroxysms of dyspnoea probably 
due to spasm of the annular bronchial muscles. 
Signs during a paroxysm. 
IWSJPJECTIOJST. 

POSTURE, standing or sitting with elbows on the 

knees or resting upon some support. 
EXPRESSION OF ANXIETY and distress. 
NOSTRILS dilated, MOUTH open. 
PERSPIRATION profuse, commonly. 
STERNO-CLEIDO-MASTOID MUSCLES rigid and 

prominent. 
CYANOSIS of the face and neck may become very 

marked, conjunctivae congested. 
CHEST approaches the barrel-shape or inflated type 

in cases of long standing or great frequency. 
CHANGES OF POSTURE usually very deliberate. 
RESPIRATORY MOVEMENTS restricted. 



SIGNS IN THE DISEASES OF THE CHEST 133 

Dyspnoea (orthopnoea) chiefly expiratory, and res- 
piration not necessarily increased in rate, but 
may be decreased. 
Inspiratory Movements short and quick. 
Expiratory Movements prolonged. 
PALPATION, MENSURATION, and PERCUS- 
SION signs not specially significant except when 
emphysema has developed. 
PULSE small, feeble, and rapid in proportion to the 
deficient aeration of the blood and overdistention 
of the right heart. 
SURFACE OF THE BODY cold and moist (clammy). 
AUSCULTATION gives 

COG-WHEEL RESPIRATION, harsh. 
RALES. 

Dry (sonorous and sibilant). 
Chiefly in Expiration. 
Over Whole Chest. 
Obscuring Vesicular Murmur. 
Loud enough, usually, to be heard at a distance 
from the patient (wheezing). 
Moist (large and small, subcrepitant), 

In the Later Stage in proportion to the bron- 
chitis with accompanying secretion. 

EMPHYSEMA OF THE LUNGS. 

Definition : an abnormal inflation of the lung from loss 
of elasticity, overdistention of the air-vesicles, and in 
pronounced cases more or less destruction of the alveolar 
walls by rupture, with accumulation of air in the inter- 
lobular connective tissue. 

Signs : in senile emphysema, where atrophy of the lungs 
is the chief feature, and in moderate emphysema, there 
is little change in the shape of the chest. 
INSPECTION in well-marked cases. 



134 PHYSICAL DIAGNOSIS OF THE CHEST. 

FACE apt to be dusky and frequently more or less 
swollen. 
Eyes prominent and watery, conjunctivae injected. 
Lips, end of Nose, and Tongue bluish. 
Nostrils dilated. 
ALONG ATTACHMENT OF DIAPHRAGM there is 
frequently a zone of dilated venous capillaries, 
though this is not peculiar to emphysema. 
POSTURE, stooping. 

STERNO-CLEI DO- MASTOIDS tense and prominent. 
NECK apparently shortened and thick, owing to the 

elevation of the sternum and shoulders. 
SHOULDERS elevated and drawn forward. 
FORM of the chest barrel-shaped. 
General Contour rounding out. 
Upper JPart of Sternum, 

Infra-clavicular and Mammary Hegions prom- 
inent. 
Antero-posterior Curvature of the spine increased, 

and therefore 
Antero-posterior Diameter of the chest increased. 

May be even greater than the transverse. 
Vertical Diameter apt to be decreased. 
Lower Part of Chest usually contracted, but it 
may be dilated, with a wide obtuse costal angle. 
Intercostal Spaces wide, especially at the upper 

part of the chest. 
Supra-clavicular fossse may be deepened or shal- 
low, or bulging, especially during cough. 
Scapulm separated widely. 

Deep Transverse Depression sometimes present 
across the abdomen at the level of the twelfth 
rib, especially during expiration. 
General Emaciation. 
RESPIRATORY EXPANSION diminished. 
Breathing Chiefly Diaphragmatic* 






SIGNS IN THE DISEASES OF THE CHEST. 135 

Ribs and Sternum move upward and forward as 

if made of one piece. 
Intercostal Spaces and supra-clavicular fossse fall 
in markedly during forced inspiration, and bulge 
out during expiration and cough. 
False Bibs and neighboring interspaces retract 

during inspiration. 
Dyspnoea more or less persistent and exaggerated 
by attacks of bronchitis, asthma, and on ex- 
ertion. 
Inspiratory Act short and quick. 
Expiratory Act distinctly prolonged. 
APEX BEAT of heart not usually visible, except in 
the area of cardiac flatness ; the pulsation of the 
enlarged right ventricle is communicated to the epi- 
gastrium through the left lobe of the liver. 
JUGULARS prominent, and sometimes pulsate. 
PALPATION. 

SKIN dry and harsh. 

VOCAL FREMITUS frequently enfeebled, but it may 

be normal or exaggerated. 
APEX BEAT rarely palpable; frequently there is a 
systolic impulse in the lower sternal and epigastric 
regions. 
MENSURATION shows the barrel 
SHAPE of the chest and 

DIMINISHED RESPIRATORY EXPANSION. 
PERCUSSION yields 

HYPER- RESONANCE, bilateral ; in exaggerated cases 

the note is high-pitched, vesiculotympanitic. 
AREA of pulmonary resonance reaches lower than 
normal, and may extend to the costal margin, less- 
ening the dulness over the heart, liver, and spleen, 
and encroaching upon or obliterating the areas of 
flatness. 
A USC UL TA TION. 



136 PHYSICAL DIAGNOSIS OF THE CHEST. 

RESPIRATORY SOUNDS. 
Length. 

Inspiratory Sound delayed and shortened. 
Expiratory Sound prolonged, and may be two 
or three times as long as the inspiratory. 
Quality, Pitch, and Intensity. 

In typical cases both sounds are low in pitch, 
soft 9 breezy in quality, and diminished in in- 
tensity y but frequently they are harsh and 
blowing. 
ADVENTITIOUS SOUNDS. 

Dry Crackling or crumpling at the end of inspira- 
tion and beginning of expiration, supposed to be 
produced in the wall of the vesicles. 
VOCAL RESONANCE is increased, diminished, or 

normal. 
HEART SOUNDS usually feeble, those at the apex 
displaced downward and to the right, sometimes 
distinct in the epigastrium. 

Pulmonary (second) sound may be distinct, and 
may be accentuated, though the thickness of the 
lung in front of the heart, especially over the 
base, may interfere with its transmission. On 
this account all sounds at the base are frequently 
feeble. 
Murmurs of relative tricuspid insufficiency may 
be heard when there is great dilatation of the 
right ventricle, but have seldom been noted. 

ATELECTASIS. 

Definition : congenital (apneumatosis) or acquired col- 
lapse of the lung. 
Signs. 

INSPECTION usually discovers the subject a 
WEAK SICKLY INFANT. 
PALLOR or DUSKINESS of the surface. 



SIGNS IN THE DISEASES OF THE CHEST. 137 

EMACIATION and evident great prostration. 
RESPIRATORY MOVEMENTS feeble. 

Hxjperpncea, in children 60 to 80 per minute, 

common. 
Hhythm of Respiration altered, the pause follow- 
ing instead of preceding inspiration. 
Dyspnoea marked without relatively proportionate 

lividity. 
Retraction of the Intercostal Spaces and Lower 

Ribs marked during inspiration. 
In the Newly-born apneumatosis is denoted 
by shallow, rapid respiration, feebleness of 
the cry, dyspnoea, especially evident in in- 
ability to nurse properly, and absence of 
cough. 
FALTATION. 

EXTREMITIES cold. 
PULSE feeble and rapid. 

VOCAL FREMITUS normal or slightly exaggerated 
over the base of both lungs. 
PERCUSSION is less satisfactory in children than in 
adults. 
NORMAL RESONANCE, if the collapsed vesicles are 
so few or small and scattered as to be marked by the 
resonance of adjacent over distended lung. 
DULNESS more or less marked over the affected 
parts where of considerable area. 
AUSCUL TA TION. 

VESICULAR MURMUR frequently normal w r here the 

percussion note remains normal. It is diminished, 

and the breathing harsh and broncho-vesicular over 

large patches of collapsed lung. 

RALES are usually numerous except in apneumatosis. 

LOBAR PNEUMONIA. 

Definition : an acute infectious disease, characterized 



138 PHYSICAL DIAGNOSIS OF THE CHEST. 

locally by inflammation of the lung, clinically mani- 
fested in three stages. 
FIRST STAGE, ENGORGEMENT. 
SECOND STAGE, CONSOLIDATION (red and gray 

hepatization). 
THIRD STAGE, PROGRESSIVE RESOLUTION. 
Signs : for convenience the signs of the three stages will 

be considered under each of the methods of physical 

examination. The signs of the first stage are usually 

present within the first twenty-four hours unless the 

pneumonia is central. 
INSPECTION. 

POSTURE is often on the affected side. 

CIRCUMSCRIBED FLUSH, mahogany colored, over 
one or both cheeks. 

GENERAL PALLOR, occasionally at the onset the face 
has a dusky hue ; later sallow. 

LIPS, deep red at first, they become cyanosed with 
greatly disturbed circulation and pale at the 
crisis. 

HERPES labialis very frequent (50 per cent, of cases, 
Osier) ; at times herpes on cheeks, nose, and eyelids. 

SUDAMINA accompany profuse sweating. 

JAUNDICE, more or less marked, is common and an 
early sign, not apparently related to hepatic en- 
gorgement, but probably due to duodenitis. 

EXPRESSION anxious, eyes bright at first, later dull 
or expressionless. 

INTERCOSTAL SPACES not filled out as in pneumo- 
or hydrothorax. 

RAPID LOSS OF FLESH apparent in a few days. 

DELIRIUM active, violent, or low and muttering. 

SUBSULTUS TENDINUM attends the great prostra- 
tion of the " typhoid state." 

CONVULSIONS may usher in the attack in children. 

RESPIRATORY MOVEMENTS of the affected side 



SIGNS IN THE DISEASES OF THE CHEST. 139 

restricted, markedly so in extensive consolidation 
of the lower lobe ; exaggerated movements of the 
healthy side. In double pneumonia respiratory 
movements largely diaphragmatic and inferior 
costal. 

Hyperpnoea always present, 30 to 80 per minute. 
Ratio between respiration and pulse, 1 to 2 or 
even 1 to 1.5. 
Dyspnoea frequent, panting in character. 
Inspiratory Act short and superficial. 
Expiratory Act often associated with a grunt, 
especially in children. Dyspnoea depends 
upon various factors : 
Amount of lung involved, 
Rapidity of involvement, 
Fever, 
Pain, and 

Derangement of the nervous system. 
Cough frequent, short, hacking, dry in the first 
stages, soon becoming looser with rusty sputum, 
and during resolution with profuse expectoration. 
MENSURATION may show, in the second stage, a 
very slight increase in the volume of the affected side 
during expiration. 
PALPATION discovers the 

SKIN usually hot and dry till the crisis, but it may 

be moist from the onset (a favorable sign). 
PRESSURE may elicit deep-seated tenderness. 
VOCAL FREMITUS in the 

First Stage is not aifected ; in the 
Second Stage, greatly increased over the consolida- 
tion, unless this be central or pleuritic effusion 
covers it, or the large and medium-sized bronchi 
become blocked (massive pneumonia), or if 
there is complicating bronchitis with free secre- 
tion. 



140 PHYSICAL DIAGNOSIS OF THE CHEST. 

Third Stage, progressive return to the normal type. 
FRICTION FREMITUS may be obtained in some cases 

owing to accompanying pleuritis. 
LOCATION OF APEX BEAT may show the heart 

slightly displaced away from the affected side. 
PULSE, 
Hapidity. 

In Mild Cases, from 90 to 120. 
In Severe Cases, from 120 to 160. 
In Children, 100 to 200. 
Volume and Tension. 
At Onset it is full, bounding. 
After the Third or fourth day it becomes com- 
pressible, small, weak, and may be dicrotic 
and intermittent in unfavorable cases. 
In Old Age the radial pulse is not reliable, and 
the pulse should be taken at the apex beat. 
FEBCUSSION. 

FIRST STAGE. 

Dulness increasing at the end of the first stage ex- 
cept in central pneumonia. The note may some- 
times be vesiculotympanitic. 
SECOND STAGE. 

Marked Dulness over the consolidation with a 
sense of resistance to the pleximeter finger, less 
than in pleurisy with effusion. In children the 
note over the affected part is not rarely high 
pitched but tympanitic. Flatness is in them 
apt to be masked, owing to the resiliency and 
thinness of the chest-wall. 
Hyper-resonance over the healthy parts. 
Tympanitic Note occasionally, 

Over Healthy Lung adjacent to consolidation. 
Over a Consolidated Upper Lobe due to con- 
duction of resonance from the trachea and 
main bronchi. 



SIGNS IN THE DISEASES OF THE CHEST. 141 

Cracked-pot Note occasionally over relaxed lung 
adjacent to the consolidation. 
THIRD STAGE. 

Dulness slowly diminishing with progressive reso- 
lution ; normal resonance established only after 
weeks. 
AUSCUL TA TION. 

RESPIRATORY SOUNDS are — 

Early in the First Stage feeble, and apt to be dry 

and somewhat harsh over the affected part. 
Later it becomes broncho-vesicular. In the 
Second Stage. 

Bronchial Breathing*, provided the large bronchi 

are patulous. 
Exaggerated Breathing over the healthy lung. 
Third Stage. 

Breathing becomes broncho-vesicular, approach- 
ing the normal. 
VOCAL SOUNDS. 
First Stage normal. 
Second Stage. 

Bronchophony and frequently 
Pectoriloquy are characteristic of complete con- 
solidation. 
JEgophony not uncommon about the upper level 
of the fluid if little pleuritic effusion accom- 
pany the consolidation, voice sounds being ab- 
sent or indistinct below. 
Third Stage. 

Bronchophony and Pectoriloquy give place to 
exaggerated vocal resonance approaching the 
normal sounds. 
ADVENTITIOUS SOUNDS. 
First Stage. 

Crepitant Rales, lasting usually from 12 to 24 
hours. These may be 



142 PHYSICAL DIAGNOSIS OF THE CHEST. 

Absent. 

(1) If stages follow each other rapidly. 

(2) In pneumonia complicating rheumatism. 

(3) In lobes secondarily attacked. 

(4) They are absent oftener in pneumonia 
of children than in adults. 

Second Stage. 

Subcrepitant Rales may or may not be present. 
Third Stage. 

Crepitant Rales return, " crepitant rale redux," 

but are largely obscured by the coarser 
Subcrepitant Rales, which are frequently accom- 
panied by a few dry rales and more or less 
large mucous rales. 

LOBULAR OR BRONCHO-PNEUMONIA. 

Definition : this is essentially an inflammation of termi- 
nal bronchi, with their branches and surrounding air- 
vesicles, which make up the pulmonary lobules. It 
occurs in the course of bronchitis, extending to the 
finer tubes, and is manifested in isolated or in groups of 
lobules. These show interstitial inflammation of both 
tubes and air-cells, both being filled with a muco- 
purulent secretion. 
Signs : these are not distinctive unless there is considera- 
ble consolidation, and even then rarely sufficient for 
diagnosis without the aid of history and symptoms. 
INSPECTION shows the patient usually 
AN INFANT or in ADVANCED AGE. 
FACE PALE and ANXIOUS, becoming CYANOTIC in 

severe cases. 
E M AC I AT I O N very rapid. Chest bilaterally retracted 
at the lower part, where there is extreme pulmo- 
nary collapse in children. 
DYSPNOEA marked. 

Inspiration often shortened and 



SIGNS IN THE DISEASES OF THE CHEST 143 

Expiration lengthened. 
HYPERPNCEA constant. 
RESPIRATORY MOVEMENTS DEFICIENT. 

Slight expansion of the ribs. 

Elevation of the chest-wall at the upper part, and 
retraction of the soft parts and lower ribs on 
inspiration. 
COUGH dry, hacking, non-paroxysmal, painful. 
RESTLESSNESS and jactitation in children gives 

place to lethargy with advancing consolidation and 

obstruction of the bronchi. 
PALPATION may elicit 

VOCAL FREMITUS, slightly increased over small 

areas, where neighboring lobules are consolidated. 
PULSE often reaches 140 to 150 per minute; small, 

compressible, feeble after the first twenty-four 

hours. 
PERCUSSION. 

DULN ESS more or less marked, but in patches usually, 

bilateral and limited to the posterior and lower 

regions of the chest ; sometimes unilateral. 
HYPER-RESONANCE over upper and anterior part 

of chest where functional emphysema occurs in the 

corresponding part of the lungs. 
A USCULTA TION. 

VESICULAR MURMUR feeble. 
BRONCHO-VESICULAR and bronchial respiration. 
VOCAL FREMITUS exaggerated. 
RALES, moist and high-pitched over the lower part 

of the chest, irregular in time and place. 
UNDEFINED MUCOUS CLICKS, on forced respira- 
tion. Signs of emphysema are frequently found over 

the anterior and upper part of the chest. 

PULMONARY TUBERCULOSIS. 

Definition : this affection is extremely varied in its pri- 



144 PHYSICAL DIAGNOSIS OF THE CHEST. 

mary location and manner of development, and there- 
fore needs a few words of introduction. 

It is characterized etiologically by the entrance 

of tubercle bacilli into the lungs with the respired 

air or through the lymphatic or blood-vessels. 

Pathologically, therefore, the initial tubercle 
may result early in (1) bronchial ulceration, or 
the initial lesion may be in the small tubes of 
one or more lobules, giving the usual early catar- 
rhal signs of (2) tubercular bronchiolitis, as so 
often manifested at one or the other apex, and 
followed pari passu by the signs of consolida- 
tion as the neighboring vesicles become involved. 
Again, sudden rupture of a bronchial lymphatic 
gland or other tuberculous focus, with aspiration 
of its infectious contents into the bronchi of 
many lobules, may result in rapidly developing 
(3) caseous pneumonia, involving more or less 
of one lobe. Finally, the entrance of a large 
number of tubercle bacilli into the circulation, 
from a primary systemic focus, and their wide 
dissemination in the lung (as well as in many 
other organs), results in (4) acute miliary tuber- 
culosis, the pulmonary signs of which are insig- 
nificant. 

The morbid pulmonary conditions which may 
appear in the course of pulmonary tubercu- 
losis, more or less slow in its progress, are 
tubercular bronchitis, lobular and lobar con- 
solidation, the formation of cavities, abscess, 
compensatory emphysema, fibrosis and calci- 
fication, bronchiectasis, oedema, collapse, and 
pleuritis, with or without effusion or pneumo- 
thorax. 
Signs of pulmonary tuberculosis, beginning as a broncho- 
pneumonia. 



SIGNS IN THE DISEASES OF THE CHEST. 145 

INITIAL OR CATARRHAL STAGE before the 

advent of consolidation. 
INSPECTION. 

Color and Nutrition may not be much affected. 

Flat or "Alar Chest" more or less marked in 
many cases. 

N^o Abnormal local Retraction of the chest as yet. 

Respiratory Expansion of one or the other apex 
may be slightly deficient or apparently lagging 
as compared to the other. 

No Hyperpncea as yet. 
PALPATION and mensuration negative, or 

Pulse rate slightly increased, and 

Respiratory Expansion deficient at one apex. 
PERCUSSION negative, or at most very slight dul- 

ness from deficient expansion. 
AUSCULTATION. 

Respiratory Murmur frequently feeble, having 
interrupted or cog-wheel rhythm, and accom- 
panied by 

Subcrepitant Rales, which may be feeble, few, 
and distant at an early stage, but become more 
distinct. Later and sometimes early the respira- 
tory murmur may be harsh, occasionally there are 

A Few Sibilant Rales. 

A Mucous Click or friction or indistinct crumpling 
sound may be heard. It is of great importance 
that the patient, during examination of the res- 
piratory sounds, be made to breathe both deeply 
and superficially, and to cough occasionally, other- 
wise obscure signs, as indistinct rales, may be 
overlooked. 

STAGE OF CONSOLIDATION (tuberculosis). 

INSPECTION yields, in addition to the signs of the 
first stage, 
Pallor and Emaciation. 
10 



146 PHYSICAL DIAGNOSIS OF THE CHEST. 

Hectic Flush, and frequently very red lips. 
Tenia Versicolor, common on the surface of the 

thorax and other parts. 
Retraction of the supra-clavicular and infra- 
clavicular region at the affected apex. 
Hyperpncea, superficial breathing and a tendency 

to cough on deep inspiration. 
Apeoo Beat enlarged in area and abnormally rapid. 
PALPATION. 
Skin hot and dry, or apt to be bathed in perspira- 
tion. 
Mespiratory Movements diminished. 
Vocal Fremitus increased over consolidation. It is 
normally greater at the right apex than the left. 
Vocal fremitus may be diminished if the pleura 
is greatly thickened over the consolidated lung. 
Fulse rate usually above a hundred. 
PERCUSSION. 

Dulness above and over the clavicle, or in the 
supra-scapular region, early ; proportionately 
more extensive with the advance of consolida- 
tion. The two apices should be percussed while 
the patient holds his breath after full inspira- 
tion, especially to elicit the presence of but slight 
dulness. 
Dulness corresponds to the consolidation in any 

part of the lung. 
Deep-seated consolidation with overlying normal 

lung may not be detected. 
A small portion of superficial consolidation, with 
underlying and surrounding overdistended 
lung, may not be easily detected. 
Dulness in any case may be in part due to the 
simple acute pneumonia surrounding tuber- 
cular consolidation, which may clean up, leav- 



SIGNS IN THE DISEASES OF THE CHEST. 147 

ing only the smaller area of dulness due to 
the tubercular part. 

Tympanitic Resonance at times may be obtained 
over consolidation adjacent to the trachea. 
AUSCULTATION. 

Respiratory Sounds are apt to be harsh and 
broncho- vesicular or purely bronchial, according 
to the amount of consolidation. 

Whisper and Vocal Resonance are apt to be ex- 
aggerated and bronchial. The latter amounts to 
pectoriloquy when the consolidation surrounds a 
large bronchus. 

Heart Sounds are apt to be exaggerated over neigh- 
boring consolidation, and the second pulmonic 
sound is frequently accentuated. 

Adventitious Sounds are more or less numerous. 
Rales large and small, dry and moist, often pe- 
culiarly sticky in character. 
Friction Sounds are often present, due to cir- 
cumscribed pleuritis. 
STAGE OF THE FORMATION OF CAVITIES. 
INSPECTION shows usually — 

Pronounced Anceniia and Emaciation, and in 
exaggerated cases signs of poor circulation, such 
as local cyanosis of lips, nose, and extremities. 

Clubbing of the Fingers. 

Face is apt to bear the impress of prolonged 
wasting illness, drawn haggard expression (ex- 
ceptionally cavities may be formed in cases 
apparently healthy). 

Marked Depression of the chest from retraction 
of the affected lung. 

Respiratory Movements limited, on the affected 
side and abnormally rapid. 

Apejc Beat rapid, weak, and frequently displaced 
toward the affected side. 



148 PHYSICAL DIAGNOSIS OF THE CHEST. 

PALPATION. 

Vocal Fremitus increased over a cavity if empty 
and freely communicating with a bronchus. 

Mhonchal and Friction Fremitus commonly 
present. 

Fulse small, compressible, feeble, and rapid. 
PERCUSSION in the stage of cavities (see also pages 
73 and 74). 

Dulness of consolidation is modified by the res- 
onance of a cavity. 

Amphoric or Cracked-pot Resonance when a 
cavity communicates more or less freely with a 
bronchus. The resonance disappears w T ith the 
filling of a cavity with fluid. Sometimes even 
a large cavity communicating freely with a 
bronchus gives dulness or cracked-pot resonance 
when the patient's mouth is closed, but marked 
amphoric resonance with the mouth open (see 
Wintrich's change of sound, p. 73). 

Small cavities deeply located are not easy and are 
often impossible to locate by percussion. 

Numerous Isolated Cavities at the apex without 
much fibrosis or pleuritic thickening may give 
resonance not far from the normal vesicular res- 
onance, in contrast to the auscultatory signs. 
AUSCULTATION in the stage of cavities when the 
cavity is empty and freely communicates with a 
bronchus. 

Respiratory Sounds. 

Cavernous Respiration, soft blowing or puffing 
in character, the expiratory sound prolonged 
and low-pitched. 
Broncho-cavernous Respiration, when the cav- 
ity is not large and is surrounded by consoli- 
dation. 
Amphoric Respiration, which is more metallic 



SIGNS IN THE DISEASES OF THE CHEST. 149 

and resonant than cavernous respiration, is 
heard in exceptional cases. 
Vocal and Whispering Sounds correspond in 
change to the respiratory sounds. Vocal res- 
onance amounts to pectoriloquy. If the cavity 
is filled with fluid or its opening closed none of 
these sounds may be heard. 
Ad tent it ions Sounds. 

Rales, dry and moist and gurgling. 
Metallic Tinkling*, occasionally. 
In most cases of advanced phthisis the pulmonary 
signs of all three stages may be present, de- 
pending upon the pathological condition of 
the part. 

FIBROID PHTHISIS. 

Definition : a chronic inflammatory affection of the lung 
characterized pathologically by more or less hyperplasia of 
the peribronchial, inter-alveolar, and inter-lobular con- 
nective tissue and pleura, which in contracting encroaches 
upon the lumen of vessels and air-passages. The fibrosis 
is accompanied by degenerative processes and often by 
tuberculosis. The signs in a typical case are, therefore, 
out of proportion to the relatively mild symptoms, which 
are those of chronic bronchitis. 
Signs. 

INSPECTION may reveal — 

NUTRITION and COLOR but little changed. 
FLATTENING OR RETRACTION of the chest-wall 

over the affected side. 
DEPRESSION OF THE CORRESPONDING SHOUL- 
DER, influencing posture. 
DYSPNOEA may or may not be apparent. 
COUGH frequent and variable. 

RESPIRATORY MOVEMENTS limited on the affected 
side; increased on the opposite side except late in 



150 PHYSICAL DIAGNOSIS OF THE CHEST. 

the case, after the unaffected lung has become em- 
physematous. 

HEART dislocated toward the contracted lung, as 
evidenced by the apex beat. 
PALPATION frequently elicits — 

EXAGGERATED VOCAL FREMITUS over the con- 
tracted lung, though the greatly thickened pleura 
and contracted bronchi may diminish vocal fremitus 
in some cases. 

PULSE more or less rapid according to the inter- 
ference with respiration or the amount of infection 
or fever present. 
PERCUSSION gives— 

DULNESS over the affected part. 

EXAGGERATED RESONANCE on the sound side, fre- 
quently extending across the mid-sternal line and 
to the limits of the pleural cavity (to the costal 
arch) below. 
AUSCUL TA TION gives— 

BRONCHIAL BREATHING and BRONCHOPHONY, 
and frequently feeble respiration on the affected 
side. Vesicular murmur absent. 

EXAGGERATED OR NORMAL breathing on the 
sound side. 

VOCAL RESONANCE more or less bronchial over 
the affected side. 

ADVENTITIOUS SOUNDS variable. 

RALES dry or moist are common. 

PULMONARY HYPEREMIA. 

Definition : excess of blood in the pulmonary vessels 

(active or passive). 
Signs not distinct, apart from sudden dyspnoea and other 

signs of pulmonary oedema. 



SIGNS IN THE DISEASES OF THE CHEST. 151 

PULMONARY CEDEMA. 

Definition : a serous transudate into the vesicular and 
interstitial tissues of the lung. It usually affects the 
most dependent parts of the lungs. 
Signs. 

INSPECTION and PALPATION. 

CYANOSIS. 
• HYPERPNCEA. 

DYSPNCEA (sudden in occurrence). 
COUGH with frothy sputum. 

SIGNS OF GENERAL DROPSY and its causative 
disease, such as anaemia, cardiac disease, or scor- 
butus, may be present. 
PERCUSSION. 

DULNESS over the lower portion of one or both 
lungs. 
A USCULTA TION. 

RESPIRATORY MURMUR vesicular or slightly bron- 
cho-vesicular, but feeble. 
RALES abundant, fine, subcrepitant, usually heard 

both in expiration and inspiration. 
VOCAL RESONANCE normal, or it may be slightly 

increased. 
PULMONIC SECOND SOUND is apt to be accen- 
tuated. 

PULMONARY HEMORRHAGE. 
Bronchial Hemorrhage. 

DEFINITION: hemorrhage from the wall of a 
bronchial tube or the trachea, or from a ruptured or 
eroded vessel in the wall or running across a cavity. 
SIGNS: often none at all, except cough and haemopty- 
sis. During hemorrhage and for hours following 
it, may be found 
RALES large and small, moist in character, over the 
same part of the chest, and 



152 PHYSICAL DIAGNOSIS OF THE CHEST. 

FEEBLE RESPIRATION and perhaps slight dulness. 
Pulmonary Apoplexy. 

DEFINITION: extravasation of blood from a rup- 
tured vessel into the lung tissue. It is rare, and 
usually occurs in the lower lobes. 
SIGNS. 

INSPECTION usually reveals if the hemorrhage is 
large. 
Dyspnoea with cough and haemoptysis. 
PALPATION practically negative. 
PERCUSSION. 
Dulness more or less extensive unless the patches 
of hemorrhagic infarcts are few and small or 
deeply seated. 
AUSCULTATION reveals — 
Early, 

Rales, moist, large and small, and possibly crepi- 
tant in the region of the hemorrhage, previous 
to coagulation. 
Later, after coagulation, the 

Respiratory Murmur is apt to be feeble or 
suppressed, especially with the blocking of a 
bronchus of large size. 
Bronchial Breathing' and Voice may be more 
or less marked in some cases. 

PULMONARY THROMBOSIS AND EMBOLISM. 
Definition. 

PULMONARY THROMBOSIS is a gradual ob- 
struction of a pulmonary artery (venous radical) or 
one of its branches by a clot formed in situ. 

PULMONARY EMBOLISM is a sudden blocking 
of a pulmonary vein or bronchial artery by a foreign 
body, usually a fragment of a vegetation from a car- 
diac valve or a fragment of a thrombus from some 
of the systemic veins. 



SIGNS IN THE DISEASES OF THE CHEST 153 

Signs. 

INSPECTION and PALPATION may reveal dysp- 
noea, cyanosis, rapid heart, and possibly pulsation of 
the jugulars, owing to dilatation of the right ventricle. 

PERCUSSION may elicit exaggerated resonance over 
the depleted area resulting from increase of air in the 
cells corresponding to the decrease of the blood in 
their walls. 

AUSCULTATION. 

RESPIRATORY MURMUR feeble or suppressed in 
the same area. 

PULMONARY ABSCESS. 

Definition: a circumscribed collection of pus within the 
lung. It usually occurs in the lower or middle lobes, 
while tubercular cavities are commonest in the upper 
lobes first. 

Signs. 

INSPECTION may reveal — 

PALLOR, EMACIATION, and evidences of pyrexia 

and prostration. 
DEPRESSION OF THE CHEST-WALL may be 
present, with atrophy of the intercostal muscles 
over a cavity where this is large and super- 
ficial. 
DYSPNCEA, COUGH, and sometimes marked bulging 
of the intercostal spaces over the cavity during cough . 
EXPECTORATION of pus in greater or less amount 
takes place when rupture occurs into a bronchus. 
This is sometimes increased in certain positions of 
the patient. 
PALPATION. 

VOCAL FREMITUS. 
Decreased at first, and 

Increased over the cavity when large, superficial, 
and freely communicating with a bronchus. 



154 PHYSICAL DIAGNOSIS OF THE CHEST. 

PERCUSSION. 

DULNESS circumscribed or general in case of pneu- 
monia, giving place to tympany over the cavity if 
of sufficient size (see p. 73). 
A VSCULTA TION. 

RESPIRATORY MURMUR feeble or absent, or some- 
times bronchial over the abscess. 

INDISTINCT RALES, and after escape of the pus the 

SIGNS OF A CAVITY. 

PULMONARY GANGRENE. 

Definition : necrosis of lung-tissue, accompanied by de- 
composition. It may occur in one or more sharply 
defined foci, varying from the size of a pea to that of a 
hen's egg, usually in the periphery of the lower lobe. 
More rarely it is diffuse, involving more or less of one 
lobe or the whole of one lung. 
Signs are not distinctive, as the same may be present in 
other forms of phthisis. 

The odor of the breath is well-nigh pathognomonic. 
INSPECTION. 
COUGH. 

Temporary in circumscribed gangrene. 
Persistent in the diffuse form. 
HYPERPNCEA largely in proportion to the amount 

of lung involved. 
CIRCUMSCRIBED DEPRESSION of the chest-wall 
toward recovery. 
PALPATION. 

VOCAL FREMITUS normal, absent, or increased. 
PERCUSSION. 

DULNESS or flatness over the gangrenous foci, and 
surrounding consolidation if sufficiently extensive. 
AMPHORIC OR CRACKED -POT resonance with the 
formation of cavities in case the patient survive. 
A USCULTATION. 



SIGNS IN THE DISEASES OF THE CHEST. 155 

RESPIRATORY MURMUR absent, or feeble bronchial 
breathing over the foci, largely dependent upon the 
openness of the corresponding larger tubes. 

AMPHORIC or CAVERNOUS RESPIRATION, with 
the formation of cavities, if freely communicating 
with a large bronchus. 

ADVENTITIOUS SOUNDS. 

Hales moist in character are apt to be present. 
Gurgling Sounds with the formation of cavities. 

PULMONARY CANCER. 

Definition : sarcoma or carcinoma of the lung rarely 
primary, and when secondary either involving the part 
by contiguity from primary affection of neighboring 
organs, as the oesophagus and liver, or metastasis, as 
emboli from a distant focus. 
Signs : these vary with the character, extent, and location 
of the tumor. The signs may be those of bronchitis, 
pneumonia, or tuberculosis in any of its stages. Nodular 
cancer may give few or all of the following : 
INSPECTION. 

CACHEXIA evident, 

LOCAL enlargement of superficial veins. 

RETRACTION of the chest-wall, depending upon col- 
lapse of the lung. 

BULGING or fulness when the tumor is large or ac- 
companied by pleuritic effusion. 
TAITA TION. 

VOCAL FREMITUS feeble or absent. 
PERCUSSION. 

DULNESS or flatness over the lung, or possibly nor- 
mal resonance surrounded by dulness. 
A USC LL TA TION. 

RESPIRATORY SOUNDS feeble or possibly bronchial. 

VOCAL SOUNDS feeble, sometimes bronchophony. 

ADVENTITIOUS SOUNDS, rales, etc., variable. 



56 



PHYSICAL DIAGNOSIS OF THE CHEST. 



ENLARGED BRONCHIAL GLANDS. 

Definition : enlargement of the lymphatic glands which 
lie at the bifurcation of the trachea and about the main 
bronchi is rare as an independent disorder, and is chiefly 
of interest as a local manifestation of tuberculosis or 
malignant growths or syphilis. 
Signs. 

INSPECTION. 

EMACIATION and hectic flush and other visible evi- 
dences of tuberculosis may be present. 
CERVICAL VEINS may be distended. 
CYANOSIS present when there is marked pressure 

upon large venous radicles. 
RESPIRATORY MOVEMENT deficient on one side as 

a result of pressure upon a main bronchus. 
COUGH dry, ringing, paroxysmal, a common sign. 
DYSPNCEA common. 
PALPATION. 

TENDERNESS in the inter-scapular region near the 
fourth or fifth rib is occasionally present. 
PERCUSSION. 

DULNESS over the glands when they are greatly en- 
larged. Dulness uniform over one side may result 
from pulmonary collapse from occlusion of the 
main bronchus. 
AUSCULTATION usually discovers — 

MURMURS, arterial and venous, from pressure upon 

corresponding vessels. 
RESPIRATORY SOUNDS feeble or absent on one 
side, owing to pressure on the main bronchus. 
Deep respiration may develop sounds not present 
in ordinary respiration. 
VOCAL SOUNDS also diminished for the same reason. 
ADVENTITIOUS SOUNDS, rales are apt to be present 
owing to the secretion within the tubes as a result 
of bronchitis. . 



SIGNS IN THE DISEASES OF THE CHEST 157 

HYDATID CYSTS OF THE LUNG. 

Rare, usually secondary to hydatids of the liver. Signs 
fairly distinct when the cysts are large. 
Signs. 

INSPECTION. 

DECUBITUS upon the sound side. 

SLIGHT BULGING of the intercostal spaces over the 

cyst, and possibly slight 
ENLARGEMENT of the affected side. 
RESPIRATORY MOVEMENT limited on the affected 
side and increased on the sound side. 
PALFATIOX. 

VOCAL FREMITUS absent over the cyst. 
FLUCTUATION may sometimes be detected when the 

cyst is large and superficial. 
FREMITUS also under these circumstances may 
sometimes be felt by one of two fingers placed 
over the part, percussion being performed upon 
the other. 
FJERCUSSIONT. 

DULNESS or flatness circumscribed over the cyst, sur- 
rounded by resonance. Dulness unchanging with 
posture of patient. 
A USCULTA TIOX. 

RESPIRATORY MURMUR absent over areas of flat- 
ness, normal or slightly broncho-vesicular imme- 
diately around it. 

PLEURISY, acute, subacute, and chronic. 

Definition : an inflammation of the pleura, characterized 
locally by early dryness of the pleuritic surfaces, fol- 
lowed by the exudation of fibrinous lymph and more or 
less fluid. The latter is attended by proportionate com- 
pression of the lung, displacement of the organs, and 
interference with normal functions. There may be more 
or less complete resolution or crippling of the lung by 



158 PHYSICAL DIAGNOSIS OF THE CHEST. 

thickening of the pleura and adhesions, with permanent 
disarrangement of normal organic relations. 
Signs. 

AT THE ONSET of an attack. 
INSPECTION. 

Posture. The patient is apt to incline his body 
toward the affected side, and in recumbency 
decubitus is likely to be upon the affected side, 
to limit the movement of the inflamed pleurae ; 
but he not infrequently lies upon the sound side, 
or upon his back, if the soreness of the pleurae 
is marked and there is great tenderness in the 
overlying chest-wall. 
Hyperpncea due to 
Fever, or in 

Compensation for shallow respiration. 
Limited Movement (slight) on the affected side to 

avoid pain. 
Increased Movement on the sound side. 
Cough, which the patient seeks to repress on 
account of pain, is a common sign as well as 
symptom. 
PALPATION may elicit — 

Friction Fremitus on the affected side. 

Surface Temperature possibly higher on affected 

side. 
Tenderness or pain upon deep pressure on affected 
side. In diaphragmatic pleurisy pain may be 
elicited at the tenth rib at the insertion of the 
diaphragm. 
PERCUSSION negative except for the production of 

pain. 
AUSCULTATION. 

Vesicular Murmur on the affected side. 

Diminished in intensity and duration owing to 
the restrained respiratory movements. 



SIGNS IN THE DISEASES OF THE CHEST. 159 

Rhythm Disturbed, jerky, cog-wheel. 
Friction Son fids. 
Pleuritic 

Area circumscribed or diffused. 
Time, with inspiration and expiration, but 
most marked in the former and broken and 
jerky in rhythm. 
Character, superficial and fine, grazing or 
coarse, creaking; or grating, rasping, or 
sawing in sound. 
Pleuro-pericardiac Friction Sounds. 

Area usually most distinct at the apex 
or along the right or left border of the 
heart, where the pleurisy is adjacent to the 
heart. 
Time, synchronous with the heart's motion, 
and accompanied by others (coarser) during 
respiration. 
Character, usually fine, grazing. 
Bronchial Hales from coexisting bronchitis (in- 
cidental). 
WHEN THERE IS MODERATE EFFUSION— 
e. g., at the level of the fifth rib in front, not suf- 
ficient to markedly displace organs or change con- 
tour of the thorax. 
INSPECTION. 

Fostnre on either side or back. 
Respiratory Movement limited on the affected 
side, now due in part to compression of the lung. 
Hyperpncea and perhaps dyspnoea. 
PALPATION. 

Restricted Respiratory Movements. 
Vocal Fremitus enfeebled over the effusion. 
MENSURATION. 

Slight loss of respiratory expansion. 
PERCUSSION. 



160 PHYSICAL TjIAGNOSIS OF THE CHEST. 

Beginning Dulness over the fluid, first noticeable 

in the infra-scapular and infra-axillary regions. 
Dulness just below the level of the fluid merging 

into flatness below. 
Elasticity wanting as felt by the pleximeter finger. 
Upper Line of Dulness not horizontal in the erect 
posture, but highest in the axillary region, de- 
scending in front and behind, forming the letter 
S curve posteriorly. 
Slight Change in level takes place slowly in change 
from the erect posture to recumbency, and vice 
versd, where no limiting adhesion exists above 
the effusion. 
AUSCULTATION. 

Respiratory Sounds feeble and distant or absent 
over the fluid, except in children, where they 
may be distinctly broncho-vesicular. 
Immediately Above the level of the fluid re- 
spiratory sounds are exaggerated or broncho- 
vesicular and harsh. 
Over the Sound Lung exaggerated respiratory 
sounds corresponding to increased function. 
Vocal Resonance. 
Over the Fluid, diminished or absent. 
At the Upper Border of the fluid occasionally 

segophony may be heard. 
Elsewhere normal. 
WHEN THE EFFUSION IS LARGE IN 
AMOUNT. 
INSPECTION. 
Posture, usually on or toward the affected side to 

give the unobstructed lung free play. 
Pallor, from anaemia, and 

Emaciation usually present, not necessarily marked. 
Cyanosis of the lips, chin, end of nose, and tips 
of extremities not infrequent. 






SIGNS IN THE DISEASES OF THE CHEST. 161 

Unilateral Enlargement of the chest on the af- 
fected side, especially the lower half. 

Nipple and Scapula farther from the median 
line. 

Shoulder elevated. 

Loiver Intercostal Spaces widened and filled out, 
rarely bulging. 

Hypochondrium prominent on the affected side, 
especially if this be the right. 

Hyperpncea, and usually dyspnoea, very marked 
on slight exertion. 

Respiratory Movements markedly restricted on 
the affected side, increased on the sound side. 

Apex Beat displaced to the right or left away from 
the effusion. 
PALPATION in large pleuritic effusion. 

Restricted Movement and Enlargement of the 
affected side. 

Intercostal Spaces widened and filled out. 

A Sense of Fluctuation sometimes obtained by 
applying the finger to the intercostal spaces and 
making percussion on the opposite aspect of the 
affected side. 

Vocal Fremitus absent over the fluid, except in 
children, where it may be present over effusions 
of considerable size. It may be conducted 
through the effusion along the line of an exten- 
sive adhesion or band. Posteriorly it may some- 
times be conducted for some distance over the 
effusion from the sound side by the chest-wall as 
a medium. 

Apex Beat displaced. 

Fulse accelerated, small in volume, low in tension, 
especially in large effusions of the left side. It 
is apt to be irregular in both time and force. 
11 



162 PHYSICAL DIAGNOSIS OF THE CHEST. 

Tender Points of intercostal neuralgia not infre- 
quently present. 
MENSURATION. 

Enlargement and loss of movement on the affected 
side. 
PERCUSSION in large pleuritic effusion. 

Flatness over a large part of the affected side. 
In the Largest Effusions all resonance disap- 
pears except over a limited area (dulness) in 
the upper inter-scapular region, over the com- 
pressed lung. Flatness may extend across the 
sternum, encroaching on the opposite lung. 
In Right-sided Effusions the liver dulness is de- 
pressed, sometimes depressed even to the navel. 
In Left-sided Effusions flatness extends to the 
margin of the ribs, masking the spleen or 
depressing it in the abdomen, and obliterating 
stomach tympany in the so-called semilunar 
space of Traube. 
Vesiculotympanitic note may be present in the 
supra-scapular and supra-clavicular region 
(Skoda). This is owing to a loss of pulmonary 
tension, or to vesicular emphysema, or possibly 
to the formation of vapor in the pleuritic space. 
Cracked-pot resonance sometimes in infra-clavicular 

region. 
Cardiac Dulness may be found to the right of 
the sternum. 
AUSCULTATION in large pleuritic effusion. 

Respiratory and vocal sounds wholly absent over 
the affected side, except feeble bronchial sounds 
in the inter-scapular region over the compressed 
lung. These are absent in extreme cases. 
Tf^hisper Resonance sometimes distinct over sero- 
fibrinous effusions, but absent over pus (Baccelli). 
Position of Heart can frequently be 'made out by 



SIGNS IN THE DISEASES OF THE CHEST 163 

the relative distinctness of its sounds, when its im- 
pulse is invisible and cardiac dulness uncertain. 
Systolic Murmurs may be heard over the heart, 
which disappear after aspiration or absorption 
of the effusion. 
AFTEB RESORPTION OF THE EFFUSION 
when the effusion has been long present. 
INSPECTION. 

Affected Side shows — 

Circumscribed Depressions or more general 

retraction. 
Displacement of the Intra-thoracic organs by 
retraction of the lung and fibrous pleuritic ad- 
hesions. 
Shoulder lowered on the affected side. 
Intercostal Spaces narrow. 
Scapulae may project in a wing-like manner. 
Spinal Column, scoliosis toward the sound side. 
Sound Side shows exaggerated normal condition. 
PALPATION. 

Apew Beat displaced. 

Vocal Fremitus exaggerated, or diminished when 
the main bronchi are contracted or the pleura 
is greatly thickened. 
Fulse, normal in rate and force where the contracted 
lung has not become tubercular. 
PERCUSSION. 

Dulness over the contracted lung. 
Hyper-resonance over the sound lung, which may 
extend across the mid-sternal line even to the 
parasternal line. 
AUSCULTATION. 

Respiratory Sounds diminished on the affected 
side and more or less bronchial. On the sound 
side respiratory sounds exaggerated, or dimin- 
ished and vesicular when emphysema has devel- 
oped. 



164 PHYSICAL DIAGNOSIS OF THE CHEST. 

PNEUMOTHORAX and PNEUMO-HYDROTHORAX. 
Definition : an accumulation of air or other gases outside 
the lung in the pleural cavity. The lung, unless bound 
by adhesions, retracts and finally exists as a collapsed 
nearly airless, fleshy mass at the upper and back part 
of the chest-cavity. There comes to be more or less 
fluid, serous or purulent, at the lower part of the cavity 
(pneumo-hydrothorax or pneumo-pyothorax). 
Signs. 

INSPECTION. 

PALLOR and EMACIATION characteristic of advanced 

phthisis. 
CYANOSIS may be marked when perforation oc- 
curs. 
ENLARGEMENT of the affected side. 
INTERCOSTAL SPACES wide and full, or bulging, 

and do not recede on inspiration. 
HYPERPNCEA and DYSPNCEA amounting to ortho- 
pnea, especially at the line of perforation. These 
may subside except on exertion. 
RESPIRATORY MOVEMENT lost on the affected side, 

increased on the sound side. 
APEX BEAT displaced usually to the opposite side of 
the chest. 
PALPATION. 

VOCAL FREMITUS, feeble or absent over the affected 

side. 
SUCCUSSION FREMITUS when present, characteristic 

of pneumo-hydrothorax. 
PULSE feeble and rapid. 
MENS UBA TION. 

ENLARGEMENT OF THE AFFECTED SIDE. 
PEBCUSSION. 

OVER THE AIR more or less tympany, varying in 
pitch according to the amount of air present and 
the degree of tension. Amphoric resonance when 



SIGNS IN THE DISEASES OF THE CHEST 165 

a large opening communicates with a bronchus. 
When the air is under great tension, as in cases 
where the opening has a valve-like action, the per- 
cussion note may be positively dull. 
OVER THE FLUID flatness at the lower part of the 
chest according to the amount present. The upper 
line is horizontal and straight, and changes with 
the posture of the patient. 
OVER THE SOUND SIDE hyper-vesicular resonance. 
A USCULTA TIOX. 

RESPIRATORY and VOCAL SOUNDS. 
Over the Air vesicular murmur absent. 
Respiratory, Vocal and Whisper Sounds when 
present are amphoric, but may be feeble. All 
respiratory and vocal sounds are absent if the 
opening into a bronchus is closed. 
Over the Fluid they are absent. 
Over the Compressed Lung, at the upper inter- 
scapular region. Respiratory and vocal sounds 
are feeble, but bronchial when present at all. 
Over the Sound Side puerile respiration. 
ADVENTITIOUS SOUNDS. 

Males when present over the affected side are me- 
tallic in character. 
Metallic Tinkling when fluid drops from the upper 
part of a cavity into the fluid ; it may also be due 
to the bubbling of air through the fluid when 
it rises above the mouth of the opening into a 
bronchus. 
Saccussion splashing sounds, upon agitation of the 
fluid by shaking the body, have a metallic quality. 
Bell or Coin Sound is produced as the ear is ap- 
plied to one aspect of the affected side while per- 
cussion is made by two coins used as plexor and 
pleximeter (see page 98). 



166 PHYSICAL DIAGNOSIS OF THE CHEST. 

FALSE PNEUMOTHORAX. 

Definition *. the term has been applied to subdiaphragmatic 
air-containing abscess cavities, usually on the right side, 
between the liver and diaphragm, occasionally on the 
left. They originate from perforating ulcers in the wall 
of the stomach or duodenum. 

Signs of a limited pneumothorax are sometimes present. 

DIAPHRAGMATIC HERNIA gives signs similar to those 

of pneumothorax, such as 
Evidence of Displaced Heart and compressed lung. 
Tympanitic Resonance. 
Respiratory Sounds absent. 
Metallic Tinkling may be absent. 
Sudden Disappearance or advent of signs due to return 

of the bowel to the abdominal cavity or to the abnormal 

position. 
Borborygmi characteristic. 

HYDROTHORAX. 

Definition : a serous transudate (non-inflammatory) into 
the pleural cavity. It is usually a part of general 
dropsy, but may occur with but slight oedema of the 
lower extremities. 

In renal disease and anaemia it is usually bilateral. 
In heart disease it is commonly unilateral, but if 

bilateral is apt to be unequal on the two sides. 
In venous obstruction it may be either unilateral or 

bilateral. 
Signs. 

INSPECTION frequently reveals 

CYANOSIS, profuse perspiration. 

EXPRESSION of anxiety. 

DYSPNCEA, orthopnoea, even without exertion ; respir- 
atory movements limited. 

ABSENCE OF INFLAMMATORY SIGNS. 



SIGNS IN THE DISEASES OF THE PERICARDIUM. 167 

PALPATION reveals 

NO TENDERNESS or rise of temperature. 

PEBCUSSION and AUSCULTATION demonstrate 
signs of unilateral or bilateral effusion, similar to 
those in pleurisy , without the presence anywhere of 
friction sounds or other evidences of inflammation. 

HEMOTHORAX. 

Definition : an effusion of blood into the pleural cavity 
as distinguished from hemorrhagic pleurisy. 

Signs largely those of hydrothorax, with evidence in the 
pallor and effect on the circulation of considerable loss 
of blood. 



DISEASES OF THE PERICARDIUM, HEART, 
AND GREAT VESSELS. 

RARE AFFECTIONS OF THE PERICARDIUM, essen- 
tially undemonstrable during life, even with the help of 
history and symptomatology. These include 

Absence or Defects of the Pericardium. 

Tumors, Hydatids, and Syphilis of the pericardium. 

PERICARDITIS. 

Definition : inflammation of the pericardium. 
Signs, in typical acute cases. 
INSPECTION. 

EXPRESSION of anxiety common ; expression of pain 

upon change of posture or deep pressure over the 

heart, or upon forced expiration. 
POSTURE, usually in dorsal semi- recumbency, or on 

the right side. 
VENOUS distention (ectasia) in the neck in rare cases 

where effusion makes pressure upon the superior 

vena cava. 



168 PHYSICAL DIAGNOSIS OF THE CHEST. 

PRECORDIAL REGION prominent. 

In Children, owing to the pliancy of the chest- 
wall. 
In Adults, rare, though it may be present with 
effusion of 12 to 15 ounces. Potain saw it with 
much less. 
INTERCOSTAL DEPRESSIONS, may be obliterated, 
or bulging of intercostal spaces may be present 
over a large pericardiac effusion (paresis of the in- 
tercostal muscles). 
BULGING OF EPIGASTRIUM occasionally present 
with a large effusion, though it does not occur 
early, owing to the ready displacement of the lungs 
before much lowering of the diaphragm is effected. 
STUPOR, DELIRIUM, CONVULSIONS, and COMA 
may occur in the late stage, with cardiac failure 
and venous stagnation. 
DYSPNCEA is usually present both early and late. 
APEX BEAT. 

Forcible and rapid, and increased in area in the 

first stage. 
Weak or absent in the presence of effusion, but 
may become both visible and palpable in forward 
inclination of the body, as in the knee-elbow 
posture. In case of moderate effusion it may 
be more appreciable in recumbency than in the 
upright posture, owing to the tendency of the 
fluid to gravitate backward toward the base in 
the former position. Weakness of the apex 
beat may also be due to simple weakening of 
the cardiac muscle, usually late. In adherent 
pericarditis sometimes at the apex there is 
a systolic drawing in followed by a diastolic 
shock. 
rALFATIOJST. 

PULSE not necessarily affected, except in rate, even 



SIGNS IN THE DISEASES OF THE PERICARDIUM. 169 

when the heart is under considerable pressure from 
effusion. 
APEX BEAT elevated apparently, and changed with 

posture. 
FRICTION FREMITUS common in the early stage. 
FEBCUSSIOJST. 

IN THE FIRST STAGE negative. 
IN THE SECOND STAGE, 

Dulness corresponds largely to the amount of 
effusion. 
Early, it is usually first to be detected at the 
base of the heart in the second interspace, and 
to the right of the sternum in the fifth inter- 
space (this is a very important sign). But 
Hare states that he has often seen the sign 
present in marked cardiac dilatation. A quan- 
tity of fluid less than four ounces may not be 
recognizable. 
Later, dulness extends to the left of the apex beat. 
In large effusions flatness and dulness occur 
in a triangular area, with its apex extending 
above the base of the heart, the base below, 
and extending far to the right of the sternum 
and to the left of the mammillary line. 
Dulness in recumbency becomes much in- 
creased in area in the upright posture, and 
the fluid may cause bulging of intercostal 
spaces which before were sunken. 

In rare cases of effusion into one part of the sac, the 
other part being bound down or shut off by adhesions, 
or when the sac becomes distended by carcinomatous 
or sarcomatous growth, percussion may give deceptive 
results. 

AUSCUL TA TIONT. 

FRICTION SOUNDS. 

Time synchronous with cardiac movements "to 



170 PHYSICAL DIAGNOSIS OF THE CHEST. 

and fro," systolic and diastolic. Occasionally- 
only occurring in systole or in diastole, they may 
be broken in time by occurring with the con- 
traction or dilatation of either auricle or ven- 
tricle, or both. They may at times disappear for 
a few beats and return. They occur independent 
of respiration, but may be somewhat influenced 
by respiration. They may be present for the 
first few hours, or may last during the greater 
part of the disease, and reappear after resorption 
of the effusion. 
Seat, over the precordia, usually first heard over 
the base, but may be loudest at the apex or over 
the right ventricle. 
Character. 

Quality, grazing, rough, harsh, or soft, and at 

times squeaking. 
Intensity variable, may be heard at a distance 
from the chest, may be increased by pressure 
of the stethoscope or by exercise, and may be 
influenced by respiration, or by the position 
of the patient — i. e. in the stage of effusion 
they may be heard in the upright position and 
be absent in recumbency. 
Duration : they usually disappear with the occur- 
rence of effusion or adhesion, but may remain 
throughout the attack. 
Propagation : they are feebly transmitted, and 
are usually confined to the precordia. 
HEART SOUNDS. 

Early, normal but rapid. 

Later, weakened, with the occurrence of a large 
effusion, which at first muffles them and later 
weakens them by weakening the heart muscle. 
Arrhythmia may occur with weakening of the 
heart muscle by pressure or adhesions. 



SIGNS IN THE DISEASES OF THE PERICARDIUM. 171 

Reduplication of the first sound is common. 
RESPIRATORY SOUNDS. 

Bronchial breathing may be developed over lung 
adjacent to and compressed by the effusion. It 
may disappear with change of posture, to reap- 
pear over other parts. With large effusions 
respiratory and vocal sounds become feeble over 
the effusion. 

MEDIASTINO-PERICARDITIS. 

Definition : inflammation leading to adhesion between 
the parietal layer of the pericardium at the base and 
the wall of the chest or mediastinal tissue. In such 
cases the two layers of the pericardium are apt to be ad- 
herent. Fibrous bands or adhesions may implicate the 
great vessels at the base, and also the pleura and 
diaphragm. 
Signs. 

INSPECTION may show— 

INTERCOSTAL SPACES retracted with each systole. 
DYSPNCEA, ARRHYTHMIA, and weakening of the 
apex beat, and other signs of pericarditis may be 
present. 
INSPIRATORY SWELLING OF THE JUGULARS has 
been noticed, probably from compression of the 
innominate vein or superior vena cava. 
PALPATION. 

PULSUS PARADOXUS has been noticed in some cases 
(see page 58). Pulse may be irregular. 
PERCUSSION. 

AREA OF CARDIAC FLATNESS may be increased, 
since adhesion of the pericardium to the chest-wall 
prevents expansion of the lung in front of the heart. 
AREA OF CARDIAC DULN ESS may be increased as 
an indication of cardiac enlargement following de- 
generation. 



172 PHYSICAL DIAGNOSIS OF THE CHEST. 

A USCULTA TIOK. 

MURMURS, systolic aortic, or pulmonic, most marked 
on inspiration, may be heard in some cases. 

HYDRO-PERICARDIUM. 

Definition : Serous transudate (non-inflammatory) into 
the pericardium, usually as part of a general dropsy. 

Signs similar to those of pericarditis with effusion, minus 
the features dependent upon inflammation and pyrexia. 
There is also the evidence of the primary disease. Ac- 
cording to Flint, the fluid is seldom sufficient in amount 
to distend the sac. 

H/EMO-PERICARDIUM. 

Definition : effusion of blood into the pericardium, 

usually sudden onset, with local 
Signs similar to those of hydro-pericardium. 

PYO-PERICARDIUM. 

Definition : purulent effusion into the pericardium. 
Signs, those of inflammatory effusion. 

PNEUMOPERICARDIUM. 

Definition : gas in the pericardium. Usually it is ac- 
companied by fluid (pneumo-pyo-pericardium). Onset 
usually sudden. 
Signs. 

INSPECTION. 

EXPRESSION anxious or pained. 
CYANOSIS, sudden collapse. This may be due to 
pressure upon the great vessels at the base of the 
heart. 
PRECORDIAL PROTRUSION of the chest-wall and 

bulging of the intercostal spaces. 
DYSPNOEA. 
FALBATION. 

PULSE rapid, weak, small, and may be irregular. 



SIGNS IN THE DISEASES OF THE HEART 173 

APEX BEAT absent, or may become visible and pal- 
pable upon forward inclination of the body. 
PERCUSSION. 

TYMPANITIC RESONANCE over the air in the upper 

part of the cavity. 
FLATNESS over the fluid. The relative position of 
these changes with the change of posture. 
A USCULTA TION. 

FRICTION SOUNDS, metallic in quality, sometimes 

audible. 
METALLIC TINKLING, or gurgling, splashing, churn- 
ing sounds, metallic in quality, sometimes heard, 
even by the patient or others. 
HEART SOUNDS, metallic in timbre. 

CONGENITAL ANOMALIES OF THE HEART AND 
GREAT VESSELS. 

Definition : the heart may be 
TOO SMALL or 

TOO LARGE, or may occupy various 
ABNORMAL POSITIONS. 
ITS CA VITIES may be too small or too large, or may 

be crossed by abnormal bands ; also 
THE SEPTA between them may be deficient, or foetal 

openings may remain patulous. 
THE AORTA and PULMONARY ARTERY may 
be abnormally small, or the PERICARDIUM AB- 
SENT. The differentiation of congenital lesions, in 
young children especially, is a very difficult matter 
as a rule. 
Signs : many of these abnormalities have existed during 
a part of the whole life without discoverable symptoms 
and signs. Absence of the pericardium is characterized 
by no signs or symptoms. Commonly congenital anom- 
alies show at some time physical evidences, of which 
the following are the chief: 






174 PHYSICAL DIAGNOSIS OF THE CHEST. 

INSPECTION. 

CYANOSIS, early in occurrence, is the most marked 
sign of congenital cardiac deformity, though its 
presence is not diagnostic, and its absence does not 
always exclude a defect. It is not infrequently 
entirely absent, slight in amount, or late in de- 
velopment. Some cases of congenital cyanosis 
may be due to abnormality of the pulmonary 
capillaries. 

FAULTY DEVELOPMENT OF THE BODY is a natural 
effect of a defective heart. 

PRECORDIAL PROTRUSION is common. 

CLUBBING of the fingers and toes, with prominence 
of the lips and nostrils, is common, and also dila- 
tation and tortuosity of the veins of the retina. 

ABNORMAL CARDIAC ACTION, arrhythmia and the 
signs of cardiac enlargement. 

DYSPNCEA is brought on or exaggerated by excite- 
ment or exertion or cough. 
PALPATION. 

PRECORDIAL THRILL not uncommon. 

PULSE is apt to be low in tension and compressible. 

SURFACE TEMPERATURE below normal. 
AUSCUL TA TION. 

MURMURS are common. According to Hochsinger, 
loud, rough, or musical murmurs, with normal or 
slight increase of cardiac dulness, are in children 
strong evidence of congenital lesions. In young 
children with loud murmurs and great increase in 
cardiac dulness and feeble apex beat congenital 
defects are suspected, the enlargement being that 
of the right heart, since acquired valve lesions 
from endocarditis are apt to affect the left heart first, 
enlargement of the right heart being a later mani- 
festation. 
Pulmonary and Tricuspid Valve Lesions are 



SIGNS IN THE DISEASES OF THE HEART 175 

treated of under Organic Valve Lesions, pages 
200-205. 

Patulous Foramen Ovale occurs, often without 
signs or symptoms. Cyanosis and dyspnoea when 
present are due to concomitant lesions. 

Murmurs, where present. 
Seat (according to Sansom). 

Anteriorly at the level of the third and 
fourth costal cartilages, to the left of the 
sternum. 
Time, systolic and presystolic murmurs present. 

Perforation of the Inter-ventricular Septum is 
apt to be revealed by signs, as there is apt to be 
greatly distended circulation. Cyanosis and dysp- 
noea marked. Other signs and symptoms vary 
with the associated valvular defects which are 
common, particularly pulmonary and tricuspid 
obstruction. A murmur has been heard. 
Seat (according to Roger). 

Upper third of the precordial space about the 
third interspace. 
Character. 

Limited area, not propagated, unaffected by 
respiration or posture. 

Patulous Ductus Arteriosus is uncommon alone, 
but not infrequent with other anomalies. Be- 
sides dyspnoea and cyanosis, aneurysmal dilata- 
tion has caused pressure upon the left recurrent 
laryngeal nerve with paralysis of the vocal cord. 

Fuluess in the second interspace. 

TJirill over the same area, systolic in time and 
accompanying a murmur. 

Haclial Pulse diminishes in size during inspira- 
tion, probably due to aspiration of blood from 
the pulmonary artery, which reduces tension in 
the aorta through the patent duct. 



176 PHYSICAL DIAGNOSIS OF THE CHEST. 

Murmur. 

Seat in the second left interspace, and also pos- 
teriorly in the left interscapular region at the 
level of the third and fourth dorsal vertebrae. 
Time, systolic. 
Character. 
Intensity. 

Increased on inspiration. 
Diminished on expiration. 
Uniform on holding the breath. 

CARDIAC ATROPHY. 

Definition : a degenerative loss of muscular volume, gen- 
erally as a result of arterio-sclerosis, which, however, 
usually causes cardiac enlargement, exceptionally atrophy. 
It accompanies general marasmus from disease or age, 
and results in diminution in the actual size of the heart, 
unless dilatation occurs. 
Signs. 

INSPECTION. 

GENERAL signs of marasmus and poor blood-supply. 
LOCAL. 

Apeoo Beat faint or absent, even under emotional 
excitement, which tends to render it more visible 
and palpable. 
PALPATION. 

APEX BEAT and PULSE weak. 
PERCUSSION. In determining the size and position 
of the heart percussion alone is unreliable in many 
cases. 

CARDIAC DULNESS diminished in both deep and 
superficial areas. Allowance must be made for the 
lung in all cases. The size of the area of super- 
ficial dulness is less modified by cardiac conditions 
than extra cardiac changes (pericardiac, pleuritic, 
and pulmonary). 



SIGNS IN THE DISEASES OF THE HEART 177 

An Enlarged Heart overlapped by lung may show 

but little dulness. 
Marked Emphysema may obliterate all dulness 

of the heart whether of normal size or enlarged. 
Retraction of the Lung with displacement of the 

heart may increase superficial dulness greatly. 
A USCULTA TION. 

HEART SOUNDS will depend upon the strength of 

the heart muscle. 
First Sound, especially weak or absent at the apex. 
Second Sound, pulmonic distinct, aortic apt to be 

weak. 

CARDIAC HYPERTROPHY. 

Definition : muscular thickening of the walls of one or 
more cavities of the heart. It rarely occurs without 
some degree of enlargement (dilatation of the cavities). 
Signs. 

INSPECTION. 

PROMINENCE OF THE PRECORDIA in children. 
APEX BEAT. 
Force increased. 
Area increased ; sometimes movement of the whole 

precordia. It extends to the left of normal. 
Epigastric Fidsation strong in hypertrophy of the 
right ventricle. 
CAROTIDS beat forcibly. 
FALFATION confirms inspection. 
PULSE regular, full, and forcible. 
FEMCUSSION. 

CARDIAC DULNESS increased to the right of the 
sternum in hypertrophy of the right ventricle, and 
markedly to the left of normal if the left or both 
ventricles are enlarged. 
CARDIAC FLATNESS increased in area from dis- 
placement of the lung. 

12 



178 PHYSICAL DIAGNOSIS OF THE CHEST. 

A T7SCULTA TION. 

In the absence of valvular lesions the heart sounds 
are apt to be sharp, loud, and often peculiarly 
ringing. 

HYPERTROPHY WITH DILATATION gives more pro- 
nounced evidences of enlargement, but the signs otherwise 
are similar as long as hypertrophy compensates. 

CARDIAC DILATATION. 

Definition : abnormal increase in the size of one or more 
of the cavities of the heart, whether the walls are atten- 
uated or normal. 
Signs. 

INSPECTION reveals— 

EVIDENCES OF POOR CIRCULATION. 

JUGULAR VEIN varicosed, and pulsating with marked 

dilatation of the right heart. 
APEX BEAT absent or very weak and undulatory in 
character, with no definite point of maximum in- 
tensity. 
PALPATION. 

PULSE and APEX BEAT weak and rapid and fre- 
quently irregular. 
PERCUSSION shows— 

DULNESS and flatness increased. 
A USCULTA TION. 

HEART SOUNDS soft, feeble, apt to be abrupt, and 
frequently of equal length. 
Second Sound may be inaudible at the apex and 

too clear at the base, and the 
First Sound feeble and may be reduplicated. 
Arrhythmia frequently present. 
MURMURS if present are apt to be of slight intensity. 



SIGNS IN THE DISEASES OF THE HEART 179 

MYOCARDITIS. 

Definition : diffuse or circumscribed inflammation of the 
wall of the heart. 
Acute, ending in suppuration, resolution, or fibrosis. 
Chronic, commonly considered as including various 
degenerations which are prone to accompany and fol- 
low inflammation. It may result from atheroma, cal- 
cification, thrombosis, or embolism of the coronary 
artery, with resulting infarction, which may be 
hemorrhagic, anaemic, or infected. The chronic form 
is apt to accompany pericarditis or endocarditis. The 
effect in some cases depends upon direct local work 
of micro-organisms, in others upon toxins or toxal- 
bumins. 
Signs, 

SIGJSTS OF ACUTE MYOCARDITIS : this form is 
present typically in typhoid fever, and also may be 
present in diphtheria, scarlet fever, cerebro-spinal 
meningitis, variola, erysipelas, and in acute endo- 
carditis and pericarditis. 

In addition to the signs of these diseases a few or 
many of the following may be present : 
INSPECTION. 
Pallor. 

Dyspnoea and Sighing Respiration. 
Apevc Beat absent. 
PALPATION. 

Coldness of the extremities. 

Pulse feeble, often extremely irregular (arrhythmia). 
PERCUSSION. 

Cardiac Dulness normal unless dilatation or peri- 
cardial effusion is present. 
AUSCULTATION. 
Arrhythmia. 
Tachycardia. 



180 PHYSICAL DIAGNOSIS OF THE CHEST. 

Heart Sounds muffled. They are apt to assume 
the foetal type. 
SIGNS OF CHRONIC MYOCARDITIS. 
INSPECTION and PERCUSSION. 

The signs of weak heart as in the acute form ; also 
Cyanosis and CEdema of the Extremities. The 
signs of acute febrile disease absent. 
PALPATION. 
Pulse shows — 

Marked Arrhythmia present early and frequently 

persistent, but little influenced by drugs. 
Irritability of the Heart upon slight excitement 
or exertion. 
AUSCULTATION. 

Heart Sounds muffled , indistinct, irregular. 
First Sound reduplicated not infrequently. 

CARDIAC LIPOMATOSIS, or fatty infiltration of the 
heart. 

Definition : an accumulation of fat upon the heart. This 
is usually a part of general obesity, although it may 
occur occasionally in lean persons. 
In modebate amount it has little or no effect upon 
the heart's function, though the amount consistent 
with health varies with age, habits, constitution, etc. 
When excessive, and deposits take place not only on 
the surface, but infiltration occurs between the muscle 
fibres, the result is hampering of the heart's action, 
and finally pressure-atrophy with true fatty degenera- 
tion, to which the resulting symptoms and signs are due. 

CARDIAC FATTY DEGENERATION. 

Definition : a more or less localized or disseminated retro- 
gressive change of the muscular fibres of the heart into 
fat, almost without exception associated with hyaline 
and fibroid degeneration. 



SIGNS IN THE DISEASES OF THE HEART. 181 

Signs : these become evident only when degeneration has 
become sufficient to cause dilatation from weakening of 
the muscular wall. 
INSPECTION may reveal 

ARCUS SENILIS and other signs of age. 
VENOUS STASIS and evidence of insufficient blood- 
supply to the organs. 
CEDE MA of the extremities is present in the late 

stage. 
DYSPNCEA may be pronounced on slight exertion. 
PALPATION. 

PULSE feeble, especially when the arm is held high. 
It is frequently irregular in both time and force, 
and may be slow. In a late stage it is always 
rapid. 
PEBCUSSIONT. 

CARDIAC DULNESS, superficial and deep, increased. 
A USCUL TA TION T . 

HEART SOUNDS weak, and are apt to be modified 
and obscured by relative murmurs (dependent upon 
dilatation). 
ARRHYTHMIA and, late, delirium cordis. 

RUPTURE OF THE HEART, traumatic or non-traumatic. 
Non-traumatic or spontaneous rupture of the heart occurs 
suddenly in case of degenerative changes, the weakened 
heart-wall being subjected to some sudden strain whether 
from mental or physical cause. It may occur in such a 
heart during perfect tranquillity of mind and body. 
The Signs obtainable are but few, owing to the sudden- 
ness of the accident. The person may, with or without 
an outcry, fall at once into collapse, or, as occurs not 
infrequently, live several hours, manifesting 
CYANOSIS, COLD SWEATS, DYSPNCEA, with, 
perhaps, convulsions and coma. In other cases, where 
the rupture is at first small, there may be attacks of 



182 PHYSICAL DIAGNOSIS OF THE CHEST. 

nausea, vomiting, anxiety, vertigo, syncope, with or 
without evidence of anginal pain. 

SYPHILIS OF THE HEART may show no signs, and 
when present they do not differ from those of myo- 
carditis and degeneration from other causes. 

ANEURYSM OF THE HEART. 

Definition : though cardiac dilatation is in so far a species 
of aneurysm, the term is limited to localized attenuation 
of the wall, acute or chronic, with circumscribed dilata- 
tion which may be distinctly saccular. 
Signs : usually neither the subjective nor objective features 
are distinctive, and the disease may be latent, revealed 
only by autopsy after sudden death, otherwise the signs 
are apt to be those of myocarditis. More or less 
CYANOSIS, 
DYSRNCEA, 
ARRHYTHMIA, 

TACHYCARDIA and other signs of weak heart. Ex- 
ceptionally there is evidence of pulsating tumor and 
increase of cardiac dulness. 
DIASTOLIC MURMURS have been heard, probably 
due to the regurgitation of blood from the aneurysmal 
sac. 

THROMBOSIS OF THE HEART (ante-mortem). 

Definition : formation of a clot within the cavities of the 
heart. This is usually adherent to its walls, and some- 
what firmly enmeshed among its tendinous and mus- 
cular bands, but it may form polypoid structures or non- 
adherent floating masses. 

Two factors usually combine to its occurrence : 
A retarded circulation. 

A toxic condition of the blood or local diseased foci 
upon the wall of the heart. 



SIGNS IN THE DISEASES OF THE HEART. 183 

Signs : the process may not be apparent during life. 
When the coagula interfere with the valves, or detached 
masses form emboli, the symptoms and signs may vary 
widely. The diagnosis is usually impossible. 

TUMORS OF THE HEART. 

Carcinoma usually secondary, by extension from neigh- 
boring structures. 

Sarcoma more rare. 

Myomata and Fibromata occasional. 
SIGJS r S very uncertain. 

PARASITES, such as Cysticercus and Echinococcus, 
are relatively rare, and their diagnosis usually impossible, 
except from their recognition in other organs and the 
presence of cardiac disturbance of more or less gravity. 

NEUROSES OF THE HEART. The so-called cardiac 
neuroses do not properly claim notice here. 

Angina pectoris and Palpitation are subjective. 
Bradycardia and Tachycardia and Arrhythmia 
are considered under the pulse. 

ACUTE ENDOCARDITIS. 

Definition : inflammation of the endocardium largely con- 
fined to the valves. It may be 

Simple, characterized by the growth upon the valves 
of vegetations of granulation tissue, capped with 
fibrin and accompanied by subendothelial, small- 
celled infiltration. The tendency of this is to 
resolution by absorption of the vegetation with 
nodular thickening and contraction. 

Malignant or ulcerative endocarditis is marked by 
connective tissue vegetative proliferation, accom- 
panied by necrosis with ulceration or suppuration. 
In either case the vegetations may be carried away 



184 PHYSICAL DIAGNOSIS OF THE CHEST. 

as emboli, to form corresponding simple or infective 
infarcts. 
Signs. 

SIGN OF SIMPLE ENDOCARDITIS : these, apart 
from the symptoms and history, are not characteristic. 
Many cases are latent, with but little or no evidence 
of cardiac trouble. When the disease is confined to 
the wall of the heart (not involving the valves) signs 
are usually absent. 
In addition to the evidences of the primary disease 
INSPECTION may reveal — 
Facial anxiety. 

Apex Beat is apt to be increased in force and area 
in the beginning. 
PALPATION elicits — 

Tulse full, bounding, and perhaps irregular. 
PERCUSSION negative in uncomplicated cases. 
AUSCULTATION may be negative, even with marked 
lesions ; but a soft 
Systolic Murmur, usually at the apex, is common. 
Reduplication of the Second Sound may be 
present. 
SIGNS IN ULCERATIVE ENDOCARDITIS. 
NOT DISTINCT apart from the septic or typhoid 
manifestations which are usually present as a part 
of the causative affection. In such cases the pres- 
ence of endocardial murmurs with other signs of 
valvular disease, and the evidences of embolic 
processes, point strongly to the diseases in question. 

CHRONIC ENDOCARDITIS. 

Definition i it is essentially a sclerosis of the valves which 
produces deformity with more or less consequent ob- 
struction or incompetence. 

Signs : when the disease is confined to the wall of the 
heart (rare) it may show no signs. Even valvular 
disease may not be recognizable by signs during life. 



SIGNS IN THE DISEASES OF THE HEART 185 

INSPECTION may disclose more or less of the fol- 
lowing : 

ANXIETY. 

CYANOSIS of the prolabia and of the nose, chin, 
cheeks, and tips of the ears is common in mitral 
regurgitation ; marked when the lesion is not com- 
pensated. 

PALLOR of the face, especially in aortic and mitral 
obstruction. 

ICTERUS common, and may be extreme, in case of 
secondary duodenal catarrh. 

CEDE MA of the extremities, progressing upward in 
case of cardiac weakness. 

PRECORDIAL PROMINENCE sometimes present in 
children with cardiac enlargement. 

APEX BEAT. 

Position : displaced to the left and downward. 
Strength : weak and invisible in dilatation ; im- 
moderately strong in hypertrophy. 

CAROTIDS show excessive beating in hypertrophy 
and in aortic regurgitation. 

JUGULAR PULSE is present in marked tricuspid re- 
gurgitation. 

DYSPNCEA on exertion amounting to orthopnoea in 
advanced cases. 
FAIT A TION. 

APEX BEAT displaced with enlargement of the ven- 
tricles. 

PULSE. 

Compressible, weak and small in cardiac incom- 
petence and frequently irregular. 
Full, bounding, powerful in hypertrophy. 
Diastolic Collapsing Artery in aortic regurgita- 
tion. 
Small, Wiry in aortic obstruction. 

FREMITUS, or thrills, correspond to the seat of the 



186 PHYSICAL DIAGNOSIS OF THE CHEST. 

murmur. Most frequent in mitral obstruction, pre- 
systolic, at the apex ; less frequently in aortic ob- 
struction, at the base ; rarely with regurgitant mur- 
murs ; common over the subclavians and carotids (sys- 
tolic) in aortic regurgitation. (See Fremitus, p. 63.) 

percussion. 

OUTLI NEOFTHEH EART is extended to the left and 
right in enlargement of the organ, according to the 
cavities affected. Often it is difficult, sometimes 
impossible, to make out by percussion the actual 
size. Evidence of enlargement is an important 
sign in differentiating from functional murmurs. 
AUSCUL TA TION. 

THE HEART SOUNDS may be 
Replaced by murmurs, 

Modified in character, muffled, accentuated, or 
Reduplicated, or otherwise more or less 
Changed in Rhythm. 
MURMURS usually accompany lesions. (See the 
various Valvular Lesions.) 
Quality. 

Obstructive murmurs usually harsh and high- 
pitched. 
Regurgitant murmurs apt to be blowing and 
soft. Either of them may be musical or 
soft, like whispered "who," or creaking or 
grating. 
Intensity and Duration. 

Sometimes Very Faint even with serious lesions. 
All murmurs are apt to become weak with 
weak heart action, grave lesions being in such 
cases not infrequently unaccompanied by mur- 
murs. Sometimes indistinct murmurs become 
loud or of changed quality and pitch after ex- 
ercise or the administration of cardiac tonics. 
In tumultuous action of the heart, especially 



SIGNS IN THE DISEASES OF THE HEART 187 

with arrhythmia, all sounds may be confused, 
and murmurs only become audible after car- 
diac stimulation. 

Sometimes Murmurs are so Loud as to be 
heard at a distance from the patient. 

Certain Postures may intensify or bring out a 
murmur. Obstructive mitral and tricuspid 
murmurs are apt to be louder in the upright 
posture, and may be feeble or absent in recum- 
bency. The reverse is true with regurgitation 
at these valves. Aortic and pulmonic mur- 
murs are not usually so much affected. 

According to Gerhardt, however, in beginning aortic in- 
sufficiency a murmur which maybe absent in recumbency 
may be heard in the upright posture, while the reverse 
is true in beginning mitral insufficiency. This is prob- 
ably due to gravity. 

JPitch varies with the lesion, and the tension and 
rapidity of circulation. It is of value in 
differentiating between two murmurs occur- 
ring at the same time. 
Time refers to the relation in the cardiac cycle. 
Systolic refers to the contraction of the ventri- 
cles (the auricles being ignored), and hence con- 
comitant with or destroying the first sound, 
and with the apex beat and carotid pulse. 
Indirect or Regurgitant. 

Mitral and Tricuspid. These are apt to re- 
place or partly obscure the heart sounds 
produced at their respective valves. They 
may last longer than the heart sounds, 
occupying nearly the whole of systole. 
Direct or Obstructive. 

Aortic and Pulmonic. These are apt to 
occur with the first sound, not replacing 
it. 



188 PHYSICAL DIAGNOSIS OF THE CHEST. 

Diastolic refers to the dilatation of the ventri- 
cle, hence not with first sound, apex beat, and 
carotid pulse. 
Direct, Obstructive. 

Mitral and Tricuspid, occurring in the latter 
part of diastole just before systole (hence 
presystolic). 
Indirect or Regurgitant. 

Aortic and Pulmonic, occurring in the first 
part of diastole, taking the place of the re- 
spective aortic and pulmonic second sound. 
Transmission or Diffusion. 

Extent : the murmur of aortic regurgitation may 
be heard very widely from its seat, even as 
low as the femoral vessels, though rarely. A 
murmur may be very limited in diffusion, as 
in mitral obstruction (heard only about the 
apex). A murmur must necessarily be loud 
to be well transmitted. 
Medium of transmission. 
The Vessels. 

The Aorta and its branches transmit the mur- 
murs of both aortic obstruction and re- 
gurgitation, which are therefore frequently 
heard above the base of the heart and 
posteriorly along the left side of the ver- 
tebral column, especially above the fifth 
dorsal vertebra. 
The Pulmonary Artery carries the pulmonic 
obstructive murmur up under the second 
left interspace, hence it is not widely dif- 
fused. 
The Sternum and Ribs. 

Loud Aortic Murmurs are frequently trans- 
mitted down the sternum owing to the 
comparative proximity of the vessel to 
the bone over ip. 



SIGNS IN THE DISEASES OF THE HEART. 189 

Mitral Systolic Murmurs are transmitted to 
the left along the ribs from the apex, 
which strikes the chest-wall at the time 
they are produced. 
The Diaphragm doubtless transmits the mur- 
mur of aortic regurgitation. The murmur 
is produced during diastole while the left 
ventricle is in most intimate contact with 
the diaphragm, the blood being directed 
downward toward it. The murmur is there- 
fore transmitted along the diaphragm to its 
attachment at the end of the sternum, and 
along the costal arch close to the left of the 
sternum. Here it is frequently heard with 
greatest intensity. 
The Blood Current within the heart. In 
general, murmurs are transmitted best in 
the direction in which the blood is flowing 
at the time the murmur occurs. 
In Mitral Obstruction the murmur is carried 
into the ventricle toward the apex with 
the blood-current. It is not usually trans- 
mitted to the left, because the apex is not 
in contact with the chest- wall at the time. 
In Mitral Regurgitation the murmur is un- 
doubtedly carried into the auricles with 
the blood, as may be verified in some 
cases where this lesion is complicated by 

CONSOLIDATION OF THE LUNG at the 

base of the heart, which transmits the 
murmur to the surface at that point, or 
where there is retraction of the lung un- 
covering the auricle anteriorly ; also in 
some cases where the left auricular ap- 
pendix is much enlarged, reaching forward 
around and in front of the pulmonary 



190 PHYSICAL DIAGNOSIS OF THE CHEST. 

artery. The normal lung, owing to the 
oblique position of the heart, is relatively 
thick over the base, and does not transmit 
the murmur. 
Seat of a murmur : the place of its greatest intensity. 
Valvular Lesions. 

AOMTIC INSUFFICIENCY. 

DEFINITION : a defect of the aortic valve, allow- 
ing regurgitation into the left ventricle during 
diastole. 
SIGNS. 

Inspection. 

Face usually pale. Anaemia is much more apt 
to be marked than in aortic stenosis or mitral 
affections (Osier). 
Precordial Region is apt to be prominent in 

children, in cases of long standing. 
Apex Beat. 

Area enlarged, reaching to the left, it may be 

even to the mid-axillary line. 
Force of impact, increased where compensa- 
tion is good, sometimes shaking the chest 
markedly or agitating the entire trunk. In 
advanced cases of this lesion the apex beat 
may seem double. The second stroke oc- 
curring during diastole is due to the impact 
of the regurgitant stream from the aorta 
against the ventricular wall (Thompson). 
Systolic Retraction of an intercostal space 
over the apex is occasionally present. It 
may be due to retraction of the lung and 
action of the heart in systole. 
Carotids and other arteries pulsate violently and 

distinctly collapse in diastole. 
Capillary Pulse (Quincke) may be seen in a line 
of artificial hyperemia drawn upon the sur- 



SIGNS IN THE DISEASES OF THE HEART 191 

face, and in the bed of the finger-nails, fundus 
of the eye, and in the mucous membrane when 
slightly pressed beneath a glass slide. 
Rhythmical Swelling- of the Uvula (Miiller) 

may sometimes be seen. 
Paint Venous pulse has been seen in the hand 

and arm (Quincke) — rare. 
Apparent Venous pulse may be due to vibra- 
tion conducted from the arteries. 
Palpation reveals also 

Apex Beat displaced, area enlarged, and force 

usually increased. 
Fremitus. 

Diastolic Thrill is rarely felt over the base 

of the heart in the aortic area. 
Systolic Thrill commonly felt over the 

carotids and subclavian arteries. 
Presystolic Thrill at the apex has been 
felt occasionally in case of aortic insuffi- 
ciency where no mitral stenosis was present 
(Schwalbe), probably corresponding to the 
functional presystolic murmur of Flint. 
(See page 193.) 
Pulse: " water hammer,^ "pistol," collapsing 
artery in diastole. When the wall of the 
left ventricle is strong the pulse is full, bound- 
ing, and sudden in systole, but falls away from 
the finger, leaving an apparently empty artery, 
in diastole. This is especially marked when 
the arm is held high, owing to the effect of 
gravity on the fall of blood directly toward 
the ventricle. Examine the arm in both the 
high and low positions and note the difference. 
Percussion. 

Cardiac Dulness over an increased area, de- 
fining the border of the heart far to the left 



192 PHYSICAL DIAGNOSIS OF THE CHEST. 

of the nipple line, owing to hypertrophy and 
dilatation. 
Cardiac Flatness much increased in area from 
enlargement of the heart and crowding back 
of the lung (see p. 177). 
Dulness may be marked in the left second inter- 
space in case of relative aortic insufficiency 
from dilatation of the aorta at its beginning. 
Auscultation. 

Murmur. When present it is of all endocardial 
murmurs most to be relied upon. 
Time : diastolic, with or obscuring the second 

sound. 
Seat : in the aortic area, second right inter- 
space, sometimes over the sternum at this 
level, occasionally over the lower end of the 
sternum and costal arch close to the left, 
over the attachment of the diaphragm. In 
the latter case. I believe the murmur is 
transmitted along the diaphragm (see p. 189). 
Character. 

Quality usually somewhat soft, gushing, or 
swishing. Occasionally rough where de- 
posits have occurred upon the valves. It 
may be musical, and especially is it apt 
to be so in relative insufficiency (Groedel). 
Intensity and pitch variable. It is usually 
loudest with large openings ; sometimes 
loudest with the arms elevated. Cases 
have been reported where the murmur 
was intermittent. 
Duration long. 
Propagation. 

Down the Sternum, owing to the proximity 

of the aorta to this bone over it. 
Toward the Apex, down the left ventricle. 



SIGNS IN THE DISEASES OF THE HEART. 193 

Along the Diaphragm to the lower part of 
the sternum and the costal arch close to 
the left. 

Above the Base of the heart, along the ves- 
sels. When the murmur is loud it may 
be very widely disseminated. 
Associated Murmurs. 

Aortic Systolic murmur may often be heard, 
due to accompanying stenosis or valvular 
rigidity or vegetation or roughness, or to 
dilatation of the aorta bevond the valve, 
or perhaps due to the fact that the sys- 
tolic wave from the ventricle is forcibly 
thrown into the aorta, the contents of 
which are at low tension from the dias- 
tolic leakage. 

Insufficiency more frequently exists alone 
than stenosis. 

Mitral Systolic murmur frequent on account 
of relative mitral insufficiency from di- 
latation of the left ventricle. The 
murmur of aortic insufficiency may be 
absent where there is a marked insuffi- 
ciency of the mitral valve (Timofejew 
and Bolkin). 

Presystolic Murmur sometimes heard at the 
apex, and may be accompanied by a frem- 
itus. 

The cause is uncertain, but probably it is due to 
vibration by the current from the auricle of the 
larger segment of the mitral valve, previously 
floated out by the refluent blood from the aorta 
(Flint). 

Systolic Murmurs are usually heard over the 
carotids and subclavians accompanied by 
a fremitus, both probably due to the sud- 

13 



194 PHYSICAL DIAGNOSIS OF THE CHEST. 

den systolic filling of these vessels, which 
were previously emptied in diastole. Both 
murmur and thrill over a subclavian may 
disappear when the arm is raised above 
the head. 
Double Murmurs (systolic and diastolic) are 
sometimes heard over the larger arteries, 
such as the femoral. 
Heart Sounds. 

Mitral and Tricuspid first sounds intact if 

the corresponding valves are competent. 
Aortic Second sound destroyed. 
Pulmonic Second sound normal or obscured 
by the loud aortic murmur. It is only ac- 
centuated with disturbed compensation, re- 
sulting in relative mitral insufficiency and 
pulmonary engorgement. This accentua- 
tion disappears with failing compensation 
of the right ventricle. 
AORTIC OBSTRUCTION. (See page 109.) 

DEFINITION : a defect of the aortic valve interfering 
with the current from the left ventricle into the 
aorta. It is a relatively rare lesion. 
SIGNS. 

Inspection. It is most common in elderly people in 
whom other visible and palpable signs of calcare- 
ous changes of the arterial system are to be found. 
Face is apt to be pale. 

Precordial Region may be prominent where car- 
diac enlargement occurs in childhood. 
Apex Beat displaced downward, sometimes to 
the sixth interspace and somewhat to the 
left. 
Area and force variable. 

Carotids and other arteries show but little pul- 
sation. 



SIGNS IN THE DISEASES OF THE HEART 195 

Yalpation. 

Apex Beat, when hypertrophy is good, is marked 

as contrasted with the small pulse. 
Fremitus, systolic thrill sometimes felt in the 
aortic area in pure aortic stenosis, which is 
rare. 
Pulse tardy, slow, small, and sometimes very 
hard and wiry. 
Percussion. 

Cardiac Dulness increased downward and to 
the left, owing to the hypertrophy of the left 
ventricle, with which there is not so much 
dilatation as in aortic insufficiency as a rule. 
Auscultation. 
Murmur. 

Time, systolic, with the first sound. 

Seat, aortic area. 

Character. 

Quality apt to be harsh, strident, sometimes 

whistling or hissing or musical. 
Intensity and pitch vary in different cases, 
and in the same case a murmur may vary 
considerably in intensity, but seldom if 
ever disappears altogether. 
Duration long, owing to the relatively slow 
discharge of the ventricle. 
Propagation. 

Above the Base, into the carotids. 
Toward the Apex, and when loud 
Down the Sternum. 
Associated Murmurs. 

Aortic Diastolic murmur is usually present, 
as pure stenosis without regurgitation is rare. 
Heart Sounds. 

Mitral and Tricuspid sounds normal, the 
former often peculiarly loud, unless rela- 



196 PHYSICAL DIAGNOSIS OF THE CHEST. 

tive mitral insufficiency exists as a result 
of dilatation of the ventricle. 
Aortic Second sound feeble. 
Pulmonic Second, normal or accentuated. 
MITMAL INSUFFICIENCY. 

DEFINITION: a defect of the mitral valve allowing 

regurgitation into the left auricle during systole. 
SIGNS. 

Inspection reveals but little abnormal, while com- 
pensation is efficient, except the signs of hyper- 
trophy in greater or less degree. When com- 
pensation fails, the visible signs are cyanosis, 
oedema, dyspnoea, cough, etc. 
Palpation during loss of compensation may reveal 
Pulse weak, small, rapid, and more or less irreg- 
ular. 
Apex Beat usually to the left, owing to enlarge- 
ment of the right heart and slight hypertrophy 
of the left ventricle. 
Percussion usually shows cardiac enlargement both 
to the right and left. Dulness may be found as 
high as the second rib, to the left of the sternum, 
owing to enlargement of the left auricle. 
Auscultation. 
Murmur. 

Time, systolic, destroying the mitral first sound. 
Seat at the apex. 

Earely it is heard with great, if not with equal inten- 
sity at the base, about two inches to the left of the sternum. 
This is thought (Naunyn) to be due to the propagation of 
the sound with the blood as it rushed into the point 
of the appendix of the left auricle, which in some cases, 
when enlarged, curves around and lies in front of the 
pulmonary artery. 

Character. 

Quality usually soft, blowing, like the whis- 



SIGNS IN THE. DISEASES OF THE HEART 197 

pered " who," occasionally rough, musical, 
hissing, or rasping, etc. 
Pitch and Intensity variable. 
Duration: it may last up to the second 
sound. 
Propagation commonly to the left of the 
apex, and when loud may be heard pos- 
teriorly at the lower angle of the scapula ; 
it is not usually heard at the base, and not 
above the base nor over the sternum. 
Heart Sounds. 

Second Pulmonic sound accentuated, owing 
to increased tension in the pulmonary artery, 
but the accentuation disappears when the 
compensatory hypertrophy of the right ven- 
tricle fails. 
MITRAL STENOSIS. 

DEFINITION : a defect of the mitral valve, inter- 
fering with the current from the left auricle into 
the ventricle. 
SIGNS. 

Inspection. 

Pallor of face and 

Cyanosis, more or less marked as compensation 

fails. 
Cough and Haemoptysis are frequent signs as 

well as symptoms. 
Epigastric Pulsation from enlargement of the 

right heart. 
Pulsation of the enlarged left auricle to the left 
and above the fourth rib, presystolic in time, 
is occasionally visible and palpable. 
Palpation. 

Fremitus, or thrill, presystolic, not infrequent at 

the apex. 
Pulse apt to be small and weak and usually irreg- 



198 PHYSICAL DIAGNOSIS OF THE CHEST. 

ular. When compensation fails it becomes 
rapid and extremely arrhythmic in both time 
and force. 
Diastolic Shock may be felt in the region of 
the pulmonary valves, where the recoil of the 
blood under high tension is exaggerated in its 
forcible closure of these valves. The sound 
of their closure is always accentuated under 
these circumstances. 
Percussion. 

Dulness often in the second interspace to the 
left of the sternum over the dilated auricle, 
and dulness also evident to the right of the 
sternum and to the left of the normal line 
when enlargement of the right ventricle is 
marked. The left ventricle usually enlarges, 
if at all, by atrophy and dilatation from poor 
nutrition. Slight hypertrophy occurs where 
stenosis is not excessive and there is accom- 
panying insufficiency. 
Auscultation. 
Murmur. 

Time, presystolic, in the latter part of diastole, 
ending in the first sound or in a systolic re- 
gurgitant murmur, which frequently is asso- 
ciated with it. 
Seat at the apex, sometimes just above and 
slightly to the left, because the left ven- 
tricle is displaced, backward to a degree and 
to the left, by the greatly enlarged right ven- 
tricle, which in this case gives the apex beat. 
Character. 

Quality, rough, rumbling, but may be va- 
riable. 
Pitch y Duration. Also variable, but it is a 
relatively prolonged murmur. Its intensity 



SIGNS IN THE DISEASES OF THE HEART 199 

often varies, being louder with the patient 
in the erect posture, and changing with 
respiration and with the rate of the heart. 
Its frequent disappearance with the ad- 
vancing age of the patient, or in disease, 
may be due to practical removal of stenosis 
with the dilatation of the ventricle. 
Propagation very limited. It is usually 
confined to a small area at the apex, and is 
not heard far to the right or left or at the 
base. 
Associated Murmurs. 

Mitral Systolic regurgitant murmur is 
usually present, as obstruction rarely occurs 
without producing some incompetence of 
the valve. 
Pulmonic Diastolic murmur from relative 
insufficiency of the pulmonary valve, due to 
continuous high pressure in the pulmonary 
artery. This is heard only when the right 
ventricle is powerful, and may be absent 
when there is relative tricuspid insufficiency. 
Tricuspid Systolic murmur from relative 
insufficiency of that valve. When compen- 
sation of the right ventricle fails the heart 
becomes extremely rapid and irregular, and 
the sounds and murmurs faint, a condition 
termed delirium cordis. 
Heart Sounds. 

Mitral first sound, when not destroyed by an 
accompanying murmur of regurgitation, is 
intact and seemingly terminates the mur- 
mur. It is apt to be accentuated and 
thumping in character. 
Tricuspid first sound is often peculiarly 
loud. 



200 PHYSICAL DIAGNOSIS OF THE CHEST. 

Pulmonic second sound is accentuated in case 
the right ventricle is hypertrophied. Ac- 
centuation disappears with failing compen- 
sation of the right ventricle. It is not apt 
to be accentuated when it is reduplicated, 
Aortic second sound is apt to be faint. 
Reduplication of the second sound is fre- 
quent, probably from the difference in ten- 
sion in the pulmonary artery and aorta. 
FULMONABY INSUFFICIENCY. 

DEFINITION: a defect of the pulmonary valve allow- 
ing regurgitation into the right ventricle during 
diastole. It is usually congenital, but may be a 
part of a general endocarditis, or relative from 
dilatation of the pulmonary artery at its beginning. 
SIGNS. 

Inspection. 

Apex Beat displaced to the left. 
Pulsation frequently visible in the 

Second Left Interspace. Pulsation of the 
Eight Ventricle between the ensiform car- 
tilage and costal arch. 
Falpation. 

Fremitus, diastolic thrill over the second left 

interspace, occasional. 
Pulse, generally regular but not large. May be 
variously affected, owing to the lesions of other 
valves usually present. 
Fercussion. 

Dulness of the enlarged right ventricle to the 
right and left of the sternum. 
Auscultation. 
Murmur. 

Time diastolic, replacing the second pulmonic 

sound. 
Seat at the base in the second interspace. 



SIGNS IN THE DISEASES OF THE HEART. 201 

Character not peculiar, except that it is in- 
creased in intensity during expiration (Ger- 
hardt). 

Propagation limited ; not transmitted into 
the cervical vessels. Being usually loud, it 
may be heard over the whole heart, distinct 
over the right ventricle. 
Associated Murmurs. 

Tricuspid Systolic murmur from relative 
insufficiency is apt to occur. 

At a distance from the heart may occasionally be 
heard on inspiration an interrupted vesicular respira- 
tion, possibly due to pulmonary capillary pulse, anal- 
ogous to the collapsing capillary pulse of aortic re- 
gurgitation (Gerhardt). 

Heart Sounds. 

Mitral and Aortic sounds apt to be weak. 
Pulmonic Secoxd destroyed by the murmur. 
Tricuspid accentuated, if hypertrophy of the 
right ventricle be adequate and no relative 
insufficiency of the tricuspid valve occurs. 
FULMOXARY STENOSIS. 

DEFINITION : a defect of the pulmonary valve in- 
terfering with the systolic current from the right 
ventricle. It is among the very rarest of acquired 
lesions, but most frequent of the congenital valve 
lesions, and usually associated with other anomalies. 
SIGNS. 

Inspection reveals deranged circulation and mal- 
formation and general arrest of development. 
Eyes prominent ; Lips thick, red. 
Superficial Veins enlarged. 
Cyanosis often extreme. 
Thorax narrow and precordia prominent. 
Abdominal Protrusion. 
Finger Ends clubbed, blue ; nails curved, thick. 



202 PHYSICAL DIAGNOSIS OF THE CHEST, 

Cardiac Impulse displaced and often increased 

so as to agitate the chest. 
Dyspnoea common. 
Palpation. 

Fremitus in the second left interspace, systolic. 
Apex Beat displaced. 
Pulse weak. 

Surface, and especially the extremities, cold. 
Percussion. 

Enlarged Right Ventricle, giving dulness to the 
right of the sternum. 
Auscultation. 
Murmur. 

Time, systolic, with the first sound. 

Seat, second left interspace, close to the 

sternum. 
Character. 

Quality harsh, and usually it is 
Intense, so that it is 

Widely propagated, but not into the arteries 
of the neck. 
TRICUSPID INSUFFICIENCY. 

DEFINITION: a defect of the tricuspid valve allow- 
ing regurgitation into the right auricle during sys- 
tole. Except in foetal life, it is usually relative, 
consecutive to valve lesions which have caused 
dilatation of the right ventricle, or to emphysema 
or some other serious protracted pulmonary dis- 
order. 
SIGNS. 

Inspection. 

Face is apt to show more or less cyanosis. In 
marked insufficiency of long standing with fail- 
ure of compensation there is marked cyanosis 
with 
(Edema of the extremities. 



SIGNS IN THE DISEASES OF THE HEART 203 

Ectasia of the superficial vessels. 

Prominence of the epigastric and right hypo- 
chondriac regions occurs from enlargement of 
the liver. 

Dyspnoea. 

Pulsation of the right ventricle evident at the 
ensiform cartilage and epigastrium. This is 
diastolic in time, not systolic. 

Jugular Pulsation present in well-marked cases, 
usually visible when there is a systolic tri- 
cuspid murmur present. 

The vense cavse and innominate vein have no valve, but 
for the production of jugular pulsation this vein must be 
sufficiently dilated to overcome the valve at its root, which 
otherwise long resists the backward pressure. 

Time, systolic. 

Seat, most marked on the right side. The bulb 
of the jugular first pulsates. Sometimes it 
may be seen just above the clavicle outside 
the sterno-cleido-mastoid. When the inter- 
nal jugular pulsates the external does also. 
Intensity : it only occurs with a relatively 
powerful right ventricle. 
Pressure easily obliterates all pulsation above 

the point of its application. 
It is greatest during inspiration. 
Hepatic Venous Pulsation is better felt than 

seen. 
Femoral Vein may pulsate if its valve (Eus- 
tachian) has been overcome by the dilatation 
of the vessel. 
Palpation. 

Apex Beat weak or absent ; instead there is a 
diffuse heaving impulse over the right ven- 
tricle, which is enlarged. It is more or less 
forcible, according to the hypertrophy present. 



204 PHYSICAL DIAGNOSIS OF THE CHEST. 

Pulse weak, rapid, unless compensation is 

good. 
Hepatic Venous Pulsation may occur, since 
these veins have no valves. 
Time, a little after the ventricular systole. 
Seat, chiefly in the left lobe, as it is most 

easily expanded. 
Intensity and character like those of an 
erectile tumor ; expansile, as may be demon- 
strated, where it is well marked, by grasp- 
ing the left lobe of the liver between the 
two hands. 
Percussion. 

Cardiac Dulness increased, and may be obtained 
well to the right of the sternum, in the plane 
of the fourth rib, owing to dilatation of the 
right auricle. 
Hepatic Dulness increased. 
Auscultation. 
Murmur. 

Time, systolic, taking the place of the tricuspid 

first sound. 
Seat at the ensiform cartilage or the lower 

half of the sternum. 
Character. 

Quality usually soft, blowing. 
Intensity and pitch not peculiar. The mur- 
mur may be absent, and is often difficult 
to make out in the presence of several 
associated murmurs. It is commonly 
overlooked, as it is apt to be tem- 
porary. 
Propagation distinct to the 

Eight of the Sternum, sometimes even as far 

as the axillary line. 
Into the Jugular Vein, where the mur- 



SIGNS IN THE DISEASES OF THE HEART 205 

mur is loud and the venous pulse well 
marked. 
Associated Murmurs of the aortic and mitral 

valves are usually present. 
Heart Sounds. 

Mitkal sound usually destroyed by incom- 
petence of the valve. 
Tricuspid sound absent. 
Aortic sound may be present, but is weak. 
Pulmonic sound weak from the low tension 
in the pulmonary artery. 
TBICUSriJD STEWOSIS. 

DEFINITION : a defect of the tricuspid valve inter- 
fering with the presystolic current (auricular sys- 
tole) into the right ventricle. It is exceedingly 
rare, and is usually of foetal origin. 
SIGNS : is generally accompanied by lesions of the 
mitral, or mitral and aortic valves, which mask it. 
Inspection. 

The signs are those of cardiac enlargement and 
of extreme systemic venous stasis, notably 
dropsy, and persistent cyanosis. 
Presystolic pulsation of the jugulars may be 
present. 
Palpation signs are not distinctive. 

Pulse usually small, irregular, and rapid. 
Presystolic Thrill over the right heart may be felt. 
Presystolic Venous Pulsation of the Liver is 
always due to organic valvular disease of the 
heart, tricuspid stenosis (Gibson). Such pul- 
sation in the liver is never present in func- 
tional dilatation of the right heart. 
Percussion may elicit 

Dulness to the right of the sternum and above 
the third rib, indicating enlargement of the 
right auricle. 



206 PHYSICAL DIAGNOSIS OF THE CHEST. 

Auscultation. So rarely has this lesion been more 
than surmised ante-mortem that the accompany- 
ing murmur has not been fully characterized. 
It is frequently wanting. 
Murmur when present. 
Time presystolic. 

Seat, over the lower two-thirds of the 
sternum, or over the fifth and sixth costal 
cartilages close to the sternum. 
Character not peculiar. 
Associated aortic and mitral murmurs. 
Where both mitral and tricuspid diastolic 
murmurs are present the difference in pitch, 
intensity, and quality, and the occurrence 
between the seats of the two of an area 
where little or no murmur is audible, aid 
in the diagnosis. 

FUNCTIONAL ENDOCARDIAL MURMURS. 

These are due chiefly to anaemia and transient causes, 
such as fever, excitement, etc. 
Time, systolic; diastolic murmurs are usually organic. 
Seat, usually the base of the heart in the pulmonary area ; 

sometimes the aortic area ; occasionally at the apex. 
Character, usually soft, blowing in quality. 
Propagation very limited. 
Associated Signs those of 

AJVJEMIA, nervous excitement. 

HEART normal in size, its sounds all present, though 
they may be slightly modified. 

ANEURYSM OF THE AORTA (THORACIC). 

Definition : a fusiform or saccular dilatation of the aorta 
in any part of its course, above the diaphragm. Its en- 
largement causes pressure, disturbing and destructive 
to neighboring organs. 



SIGNS IN THE DISEASES OF THE AORTA. 207 

Signs. 

INSPECTION may reveal 

AN INFLAMED AREA of reddened, thin, glazed skin 
covering the site of the aneurysm, if this has by 
pressure come sufficiently near the surface. 

LIVIDITY of the face, neck, and upper extremities 
from pressure upon venous trunks. Lividity and 
oedema, when sudden in occurrence, may be due to 
rupture into one of the great venous trunks. 

TURGESCENCE and VARICOSITY of the superficial 
veins points to deep-seated interference with venous 
trunks. 

EXPRESSION : the eyeballs may become prominent; 
expression of distress may indicate the more or less 
continuous boring pain commonly present. 

LOCALIZED CEDE MA results from pressure upon the 
superior vena cava or innominate vein. It may be 
absent from establishment of collateral circulation. 
Capillary turgescence may produce 

A THICK FLESHY COLLAR at the base of the neck, 
which may be unilateral. 

These pressure signs may of course be produced by other 
conditions, such as tumors, swellings, inflammatory contraction, 
thrombosis, etc. 

INEQUALITY OF THE PUPILS, or persistent bilateral 
myosis, may result from pressure upon the sym- 
pathetic nerve trunks or branches. Pupil may be 
contracted on the affected side. 
EMACIATION and ENFEEBLEMENT progressive. 
ENLARGEMENT or BULGING common at the site 
of the aneurysm ; variable in size. 
Site. Always above the fourth rib. 

None Present when the Aneurysm is located 
at the Valves of Valsalva. The signs in 
this case are apt to be obscure. 



208 PHYSICAL DIAGNOSIS OF THE CHEST. 

Bulging" to the Right of the Sternum in the 
second interspace, sometimes extending far into 
the infra-clavicular and mammary region, is 
apt to occur from aneurysm of the ascending 
portion, if large. More rarely it appears to 
the left of the sternum at a corresponding 
level. The sternum may be perforated. 
Bulging at the Upper Part of the Sternum 
and adjacent infra-clavicular region results 
from aneurysm of the transverse portion. 
Bulging Posteriorly, below the level of the 
fourth rib, to the left of the vertebral column, 
may result from aneurysm of the thoracic 
aorta, Very rarely it appears to the right of 
the vertebral column. Frequently there is an 
absence of a tumor. 
PULSATION, if visible, at the site of an aneurysm. 
Time, systolic (with apex beat). 
Character, expansile in all directions, not simply 
lifting as from a tumor lying upon a large artery. 
Intensity : to detect slight pulsation the light must 
be good. It may sometimes be detected by look- 
ing across the surface. 

Divergence of two projecting objects with each pulsation 
may reveal an otherwise slight expansion — e. g. stick upon 
the surface over the suspected part two small strips of paper, 
so that they may project several inches at right angles from 
the surface. 

DEFICIENT MOVEMENT in the arteries of the left 

side may be seen, especially in aneurysm of the 

transverse part. 
PULSATION OFTHE CAROTIDS may be exaggerated. 
APEX BEAT is apt to be displaced downward and 

somewhat to the left with corresponding dislocation 

of the heart. 
EPIGASTRIC PULSATION may be marked with en- 



SIGNS IN THE DISEASES OF THE AORTA. 209 

largement of the right heart as a result of disturbed 
pulmonary circuit. 

RESPIRATORY MOVEMENT may be deficient or ab- 
sent on one side, usually the left, from pressure on 
the main bronchus. 

DYSPNCEA and HYPERPNCEA, amounting to ortho- 
pnea, may be present, either due to laryngeal paresis 
or to interference with the lungs, trachea, or bronchi 
(especially in aneurysm of the transverse portion). 

COUGH a frequent sign with or without profuse secre- 
tion, variable. 
PALFA TION. 

AREA OF TENDERNESS over the aneurysm not in- 
frequent, and there may be tender points charac- 
teristic of intercostal neuralgia. 

CONSISTENCE of the tissue over an aneurysm may 
be soft, yielding, and even fluctuating when cartilage 
and bone have been destroyed. 

TH Rl LL systolic over the tumor a frequent sign, some- 
times very early obtained by pressure of the fingers 
in the supra-sternal notch. 

IMPULSE obtained over the tumor usually 
Systolic. 

Diastolic Shock (usually slight) may also be pres- 
ent, due to the falling back of an unusual volume 
of blood against the aortic valve, which must be 
competent to give it. (Diastolic shock absent in 
insufficiency of the aortic valve.) 

RADIAL and CAROTID pulse, or both, may be un- 
equal in volume on the two sides owing to pressure 
on the innominate artery or one of its branches, or 
to obstruction by coagulum. 

THE SUPERFICIAL ARTERIES, temporals, radials 
frequently show rigidity, inelasticity, unevenness, 
or tortuosity as a part of general atheroma. 

PULSATION OF THE ABDOMINAL ARTERY and its 
14 



210 PHYSICAL DIAGNOSIS OF THE CHEST. 

branches may be very weak in a large aneurysm of 
the descending part of the thoracic aorta. 
TRACHEAL TUGGING is sometimes an early sign. 
Dr. Wm. Ewarts's method of examination : 

Patient seated, head thrown back against exam- 
iner as he stands behind. Trachea gently 
stretched by pressure made with tips of both 
index fingers placed under the lower edge of 
the cricoid cartilage. Sensation of traction or 
tugging downward is felt with each heart-beat. 
VOCAL FREMITUS may be diminished over the an- 
eurysm or over the lung, the main bronchus of 
which is obstructed. 
FEMCUSSION must be made gently in case of sus- 
pected aneurysm for fear of causing embolism. 
DULNESS is present over the aneurysm. 
SENSATION OF RESISTANCE to the pleximeter 
may be less than over consolidated lung unless the 
aneurysm is filled with fibrin. 
DULNESS OVER THE LUNG may be present also 
when the main bronchus is compressed and the cor- 
responding lung congested or collapsed. Dulness 
over a part of the lung in which consolidation is 
due to pressure or to tuberculosis, which is apt to 
set in where the pulmonary artery is compressed. 
THE HEART is not usually enlarged when the aortic 
valve is unaffected, unless the aneurysm is large, 
but it may be displaced. 
A USCULTA TIOJST. 

MURMUR is present in about half the cases. Fre- 
quently absent in saccular aneurysm (Douglas 
Powell). 

Systolic Bruit most common. In some cases a 
murmur may only be detected by placing the 
chest-piece of the stethoscope in the patient's 



SIGNS IN THE DISEASES OF THE AORTA. 211 

mouth, his lips being closed about it (Sansom). 
The murmur is then conveyed by the trachea, 

Drummond, of New Castle, has noted a systolic murmur 
over the trachea, possibly due to expulsion of air at each 
distention of the aneurysmal sac against the trachea. 

Diastolic Murmur may sometimes be heard over 
a saccular aneurysm independent of aortic re- 
gurgitation, the second aortic sound of the heart 
being clear and loud. This murmur may be due 
to the elastic recoil of the wall of the sac forcing 
the blood back into the aorta, as represented in 
the following diagram : 




Fig. 10.— Illustrating the elastic recoil of an aneurysmal sac, producing a 

diastolic murmur. 

Diastolic Murmur of Aortic Insufficiency, taking 
the place of the second aortic sound, is frequently 
present in aneurysm involving the valves of Val- 
salva. 
VENOUS HUM in the neighborhood of the aneurysm 
may be produced by pressure against a large vein 
or perforation into the vein. It is continuous, and 
apt to be accentuated with each systole. 
SECOND AORTIC SOUND is frequently accen- 
tuated and of a ringing, drumming, or clanging 
character, unless replaced by the murmur of in- 
sufficiency. 
RESPIRATORY AND WHISPER AND VOCAL sounds 
may be 

Bronchial over a compressed lung or over the 
aneurysm when resting upon the trachea. 



212 PHYSICAL DIAGNOSIS OF THE CHEST. 

Diminished or Absent over a whole lung when 
the main bronchus is compressed. 
Forced Inspiration may in such cases give dis- 
tinct respiratory sounds, absent on ordinary 
respiration. 

COARCTATION OF THE AORTA. 

Definition : a contraction or partial stenosis of the aorta 

(rare). 
Signs. 

INSPECTION reveals evidence of cardiac hypertrophy, 
dilatation of the arch of the aorta and carotid and 
subclavian arteries, and dilatation and tortuosity of 
the superficial arteries. 
PALPATION. 

FEEBLE PULSATION in the abdominal aorta and in 

the arteries of the lower extremities. 
FREMITUS over the large arteries of the head, neck, 
and upper extremities. 
PERCUSSION negative. 
A USCULTA TION. 
MURMUR. 

Quality harsh. 
Pitch high. 

Intensity usually loud. 
Time, systolic or diastolic (post-systolic). 
Propagation into the subclavian and carotid ar- 
teries, and it may be heard posteriorly. 

ANEURYSM OF THE PULMONARY ARTERY. 

Very rare, and difficult of diagnosis, even with the aid of 

subjective manifestations. 
Signs which have been obtained. 
INSPECTION. 
CYANOSIS marked. 
DROPSY. 



SIGNS IN THE DISEASES OF THE ARTERIES. 213 

DYSPNOEA pronounced. 

PULSATING swelling limited to the second interspace 
to the left of the sternuin, where aneurysms of the 
ascending aorta are not as likely to present as those 
of the descending aorta, which commonly present 
posteriorly. 

PALPATION, systolic thrill. 

A USCUL TA TION. 

MURMUR, systolic or diastolic, and not propagated 
above the clavicle. 

ANEURYSM OF THE INNOMINATE ARTERY. 
Signs differ from those of aortic aneurysm in 

LOCATION: it presents to the right of the sternum, 
in the region of the inner end of the clavicle. 

PHESSUHE signs referable to the recurrent laryngeal 
nerve, oesophagus, and trachea are not so apt to occur 
as in aortic aneurysm. 

COMPRESSION, by the examiner, of the carotid and 
subclavian arteries diminishes the pulsation of aneur- 
ysm of the innominate artery, but does not affect aortic 
aneurysm appreciably. 



INDEX. 



Adventitious sounds, 93 
iEgophony, 90 
Alar chest, 36 
Amphoric breathing, 84 

cough, 92 

resonance, 73 

whisper, 91 
Aneurysm of the innominate ar- 
tery, 213 

of the pulmonary artery, 212 
Angle of Lewis, 32 
Aorta, aneurysm of the, 206 

coarctation of the, 212 

landmarks of the, 30 

sounds over the, 120, 121 
Aortic insufficiency, 190 

obstruction, 194 

pulsation, 48 

in the epigastrium, 52 

valves, 29 
Apex beat, 49 

in emphysema, 135 
Apneumatosis, 136 
Apnoea, 43 
Arterial movements, 48 

sounds, 120, 121 
Asphyxia, 43 
Asthma, signs of, 132 
Atelectasis, 136 
Atrophy, cardiac, 176 
Auscultation, 78, 80 
Auscultatory percussion, 124 
Axillary lines, 23 



Barrel-shaped chest, 37, 134 

Bell sound, 98 

Blood currents and murmurs, 189 

Bone resonance, 70 

Bradycardia, 60 

Breathing, abnormal, 41 

amphoric, 84 

bronchial, 82 

broncho-cavernous, 84 

cavernous, 83 

cog-wheel, 86 

exaggerated, puerile, 85 

feeble, 85 

interrupted, 86 

laryngeal, 82 

metamorphosing, 84 

normal, 40 
vesicular, 81 

rapidity of, 42 

suppressed, 86 

vesiculocavernous, 84 
Bronchial hemorrhage, 151 
Bronchiectasis, 131 
Bronchi, diseases of, 128 

primary, 28 
Bronchitis, 128-130 
Bronchophony, 90 
Broncho-pneumonia, 142 
Bruit de diable, 122, 123 

Capillary bronchitis, 129 

pulse, 49, 190 
Cardiac atrophy, 176 

215 



216 



INDEX. 



Cardiac dilatation, 178 

diseases, 167 

dulness, 29, 177 

fatty degeneration, 180 

flatness, 29 

fremitus, 63 

hypertrophy, 177 

lipomatosis, 180 

movements, 49 

rupture, 181 

sounds, 98 
modified, 100 
Carotids, pulsation of, 48 
Cavernous breathing, 83 

cough, 92 

whisper, 91 
Cavity, cracked-metal resonance 
in, 74 

in pulmonary tuberculosis, 144, 
148 
Cerebral blowing, 121 
Chest, form of, 35 

percussion of, 75 

size of, 34 
Chest- wall, diseases of, 126 
Cheyne-Stokes respiration, 44 
Cog-wheel respiration, 86 
Collapsing pulse, 191 
Color, 33 
Costal arch, 20 

breathing, 40 
Cough, varieties of, 92 
Cracked-metal resonance, 74 
Crepitant rales, 95 

in penumonia, 142 
Crepitus, 64 
Crumbling sounds, 96 

Diaphragm and murmurs, 189 
Diaphragmatic breathing, 40 
hernia, 166 



Diaphragmatic pleurisy, 158 
Diastolic murmurs, 113 

shock, 113 

in aneurysm, 209 
Diseases of the chest, 125 

of the heart, 167 

of the lungs, 157 

of the pericardium, 167 
Ductus arteriosus, patulous, 175 
Dulness, cardiac, 29, 177 

hepatic, 30 

in pericarditis, 169 

in pleurisy, 160 

in pulmonary tuberculosis, 146 

splenic, 31, 76 
Duroziez's double murmur, 122 
Dyspnoea, 42 

in asthma, 133 

in atelectasis, 137 

in pneumonia, 139 

Emphysema of the chest-wall, 127 

pulmonary, 133 
Emphysematous chest, 37, 134 
Empyema pulsans, 52 
Endocardial murmurs, 106 
Endocarditis, 183 
Enlarged bronchial glands, 156 
Epigastric pulsation, 52 
Eupnoea, 40 

Exocardial murmurs, 104 
Expiratory sound prolonged, 88 

Fatty heart, 180 
Fibroid phthisis, 149 
Fissures of the lungs, 25 
Flat chest, 36 
Flatness, 71 

cardiac, 29 

hepatic, 31 

in pleurisy, 162 



INDEX. 



217 



Flatness, splenic, 31 
Fontanelle, sounds over the, 121 
Foramen ovale, patulous, 175 
Form of the chest, 36 
Fremissement cataire, 63 
Fremitus, 63-65, 185 
Friction-sounds, 96 

pericardiac, 104, 169 

pleuritic, 159 

pleuro-pericardiac, 106 
Friedreich's change of sound, 74 
Functional murmurs, 206 
Funnel breast, 37 

Gerhard's change of sound, 74 

H^MO-PERICARDIUM, 172 

Hemothorax, 167 
Harrison's groove, 37 
Heart, aneurysm of the, 182 

congenital anomalies of the, 173 

diseases of the, 167 

fatty, 180 

landmarks of the, 29 

neuroses of the, 183 

parasites of the, 183 

relation to the lungs, 29 

rupture of the, 181 

sounds (see Cardiac), 98 

in pulmonary tuberculosis,147 

syphilis of the, 182 

thrombosis of the, 182 

tumors of the, 183 

valves of the, 29 
Hepatic dulness, 30 

flatness, 31 

venous pulsation, 48 
Herpes in pneumonia, 138 
Hydatid cysts of the lung, 157 

fremitus, 64 
Hydro-pericardium, 172 



Hydrothorax, 166 
Hyperpnoea, 42 
Hypopnoea, 42 

Innominate artery, aneurysm 
of the, 213 
landmarks of the, 30 
Inspection, 33 
Inspiratory sound, 87 
Intercostal neuralgia, 126 
Interrupted Wintrich's change of 

sound, 74 
Interval in respiration, 87 
Interventricular septum, perfora- 
tion of, 175 

Jugular murmur, 123 
Jugulars, inspiratory swelling of 
the, 171 
presystolic pulsation of the, 47 
swelling of the, 47 

Landmarks of the chest, 23 
Lines of reference, 23 
Liver, landmarks of the, 30 

relation to the lung, 30 
Lobar pneumonia, 137, 142 
Lungs, diseases of the, 128 

fissures of the, 25 

landmarks of the, 24 

lobes of the, 26 

outline of the, 24 

relation to the liver, 30 

Mammillary lines, 23 
Mediastinal pericarditis, 171 
Mediastinum, diseases of the, 128 
Mensuration, 6Q 
Metallic tinkling, 97 
Metamorphosing breathing, 84 
Mitral insufficiency, 196 



218 



INDEX. 



Mitral stenosis, 197 

valve, 30 
Movements, 39, 54 

cardiac, 49 

circulatory, 47 

respiratory, 40 
Murmurs, aneurysmal, 210 

aortic diastolic, 114 
systolic, 119 

cardiac, 104 

diastolic, 113 

endocardial, 106 

exocardial, 104 

functional endocardial, 206 

inorganic, 118 

mitral diastolic, 113 
systolic, 106, 189 

non- valvular organic, 117 

pulmonic, 112 

transmission of, 188 

tricuspid diastolic, 116 
systolic, 111 
Myocarditis, 179 

Neuroses of the heart, 183 
Normal vesicular breathing, 81 

dulness, 56 
Nutrition, 34 

Organic murmurs, 106 
Orthopnoea, 44 

Palpation, 53 
Para-sternal lines, 23 
Pectoriloquy, whispering, 91 
Percussion, 66-68 

auscultatory, 124 
of normal chest, 75 
Pericardiac friction sounds, 104 

splashing sounds, 106 
Pericarditis, 167 



Phonometry, 125 
Pigeon-breast deformity, 36 
Pleurae, diseases of the, 157 
Pleurisy, cracked-metal resonance 

in, 74 
Pleurodynia, 126 
Pleuro-pericardiac friction sounds, 

106, 159 
Plexor and pleximeter, 66 
Pneumo-hydrothorax, 164 
Pneumo-pericardiac sounds, 106 
Pneumopericardium, 172 
Pneumothorax, false, 166 
Post-tussive suction sound, 98 
Posture, 37 

in asthma, 132 

in lobar pneumonia, 138 

in pericarditis, 167 

in pleurisy, 158, 159 
Precordial bulging in pericarditis, 
168 

movement, 52 

pulsation, 54 
Pulmonary abscess, 153 

apoplexy, 152 

arterial pulsation, 48 

artery, aneurysm of the, 212 
pulsation of the, 54 

cancer, 155 

capillary pulse, 201 

gangrene, 154 

hemorrhage, 151 

hyperaemia, 150 

insufficiency, 200 

oedema, 151 

resonance exaggerated, 69 

sounds in auscultation, 81 

stenosis, 201 

thrombosis, 152 

tuberculosis, 143 
Pulsation of the epigastrium, 52 



INDEX. 



219 



Pulsation of the pulmonary artery, 

54 
Pulse, capillary, 49 

characteristics, 55-59 

collapsing, 191 

dicrotic, 57 

in asthma, 133 

broncho-pneumonia, 143 
lobar pneumonia, 140 

radial, 54 

" water-hammer," 191 
Pulsus bigeminus, 57 

paradoxicus, 58 

trigeminus, 58 
Pyo-pericardium, 172 

Quincke's pulse, 49 

Rales in asthma, 133 

in broncho-pneumonia, -43 

in lobar pneumonia, 142 

varieties of, 93 
Recurrent pulsation of an artery, 59 
Regions of the chest, 1-8 
Resonance, amphoric, 73 

cracked-pot, 74 

exaggerated pulmonary, 69 

tympanitic, 72 

vesicular, 68 

vocal, 88 
Respiration (see Breathing), 40 
Respiratory change of sound, 74 

expansion in emphysema, 135 

sounds, 80-86 
Rhachitic chest, 36 

rosary, 36 
Rhonchal fremitus, 64 
Ribs, landmarks of the, 32 

Scapula, landmarks of the, 33 
Semilunar space of Traube, 76 



Shoemakers' breast, 37 
Sibilant rales, 95 
Size of the chest, 34 
Sonorous rales, 94 
Sound, bell, 98 

elements of, 68 
Sounds, auscultatory, 80 

cardiac, 98 

cough, 91 

friction, 96 

percussion, 68 

pleuritic, 159 

pulmonary, 81 

succussion, 98, 125 

tussive, 91 

vascular, 120 

venous, 122, 123 

whispering, 91 
Spinal curvatures, 37 
Spleen, landmarks of the, 31 
Splenic dulness, 31, 76 
Sternal lines, 23 
Stethoscope, 78, 79 
Subclavian artery, sounds over 

the, 121 
Swellings of the chest-wall, 127 

Tachycardia, 61 

Thigh sound, 71 

Thoracentesis, 125 

Thrombosis of the heart, 182 

Trachea, 27 

" Tracheal tone/' 72 

" tugging," 210 
Traube, semilunar space of, 76 
Tremor cordis, 58 
Tricuspid insufficiency, 202 

stenosis, 205 

valve, position of, 29 
Tuberculosis, acute milliary, 144 
Tumors of the chest-wall, 127 



220 



INDEX. 



Tumors of the heart, 183 
Tussive or cough sounds, 91 
Tympany, 72 

Valleix's points of tenderness, 

127 
Valves, cardiac, 29 
Valvular lesions, 190 

murmurs, 106 
Vascular sounds, 120 
Veiled puff, 98 
Venous hum, 123 
in aneurysm, 211 

pulsation, 47, 191 



Venous sounds, 122 

Vertebrae, landmarks of the, 32 

Vesicular resonance, 68 

respiration, 81 
interrupted, 201 
Vesiculo-tympany in pleurisy, 162 
Vocal fremitus, 64 

sounds, 88 

Whisper, amphoric, 91 

cavernous, 91 
Williams's tracheal tone, 72, 74 
Wintrich's change of sound, 73, 

74 



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CATALOGUE OF MEDICAL WORKS. 5 



*AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. Edited by 
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Professor of Physiology, Harvard Medi- 
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JOHN G. CURTIS, M. D., 

Professor of Physiology, Columbia Uni- 
versity, N. Y. (College of Physicians 
and Surgeons). 

HENRY H. DONALDSON, Ph.D., 

Head- Professor of Neurology, Univer- 
sity of Chicago. 

W. H. HOWELL, Ph.D., M. D., 

Professor of Physiology, Johns Hopkins 
University. 

FREDERIC S. LEE, Ph. D., 

Adjunct Professor of Physiology, Colum- 
bia University, N. Y. (College of 
Physicians and Surgeons). 



WARREN P. LOMBARD, M.D., 

Professor of Physiology, University of 
Michigan. 

GRAHAM LUSK, Ph.D., 

Professor of Physiology, Yale MedicaJ 
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W. T. PORTER, M.D., 

Assistant Professor of Physiology, Har- 
vard Medical School. 

EDWARD T. REICHERT, M.D., 

Professor of Physiology, University of 
Pennsylvania. 

HENRY SEWALL, Ph. D., M. D., 

Professor of Physiology, Medical Depart- 
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W. B. SAUNDERS' 



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William Osier, Baltimore, Md. 
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Louis Starr, Philadelphia, Pa. 
Henry W. Stelwagon, Philadelphia, Pa. 
James Stewart, Montreal, Canada. 
Charles G. Stockton, Buffalo, N. Y. 
James Tyson, Philadelphia, Pa. 
Victor C. Vaughan, Ann Arbor, Mich. 
James T. Whittaker, Cincinnati, O. 
J. C. Wilson, Philadelphia, Pa. 



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CATALOGUE OF MEDICAL WORKS. 



*AN AMERICAN TEXT-BOOK OF OBSTETRICS. Edited by 

Richard C. Norris, M. D. ; Art Editor, Robert L. Dickinson, M. D. 
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Edward P. Davis. 
Robert L. Dickinson. 
Charles Warrington Earle. 
James H. Etheridge. 
Henry J. Garrigues. 
Barton Cooke Hirst. 
Charles Jewett. 



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Richard C. Norris. 
Chauncey D. Palmer. 
Theophilus Parvin. 
George A. Piersol. 
Edward Reynolds. 
Henry Schwarz. 



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of them. We cannot turn over these pages without being struck by the superb illustrations 
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instant appreciation by practitioners as well as students." — New York Medical Times. 

Permit me to say that your American Text-Book of Obstetrics is the most magnifioent 
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which alone is sufficient to place you first in the ranks of medical publishers. 

With profound respect I am sincerely yours, Alex. J. C. Skene. 



8 



W. B. SAUNDERS 1 



*AN AMERICAN TEXT-BOOK OF THE THEORY AND 
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by William Pepper, M. D., LL.D., Provost and Professor of the Theory 
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Price per Volume : Cloth, $5.00 net; Sheep or Half-Morocco, $6.00 net. 



VOLUME I. CONTAINS 



Hygiene. — Fevers (Ephemeral, Simple Con- 
tinued, Typhus, Typhoid, Epidemic Cerebro- 
spinal Meningitis, and Relapsing). — Scarla- 
tina, Measles, Rotheln, Variola, Varioloid, 
Vaccinia, Varicella, Mumps, Whooping-cough, 
Anthrax, Hydrophobia, Trichinosis, Actino- 



mycosis, Glanders, and Tetanus. — Tubercu- 
losis, Scrofula, Syphilis, Diphtheria, Erysipe- 
las, Malaria, Cholera, and Yellow Fever. — 
Nervous, Muscular, and Mental Diseases etc. 



VOLUME II. CONTAINS : 



Urine (Chemistry and Microscopy). — Kid- 
ney and Lungs. — Air-passages (Larynx and 
Bronchi) and Pleura. — Pharynx, CEsophagus, 
Stomach and Intestines (including Intestinal 
Parasites), Heart, Aorta, Arteries and Veins. 



— Peritoneum, Liver, and Pancreas. — Diathet- 
ic Diseases (Rheumatism, Rheumatoid Ar- 
thritis, Gout, Lithsemia, and Diabetes.) — 
Blood and Spleen. — Inflammation, Embolism, 
Thrombosis, Fever, and Bacteriology. 



The articles are not written as though addressed to students in lectures, but 
are exhaustive descriptions of diseases, with the newest facts as regards Causa- 
tion, Symptomatology, Diagnosis, Prognosis, and Treatment, including a large 
number of approved formulae. The recent advances made in the study 
of the bacterial origin of various diseases are fully described, as well as the 
bearing of the knowledge so gained upon prevention and cure. The subjects 
of Bacteriology as a whole and of Immunity are fully considered in a separate 
section. 

Methods of diagnosis are given the most minute and careful attention, thus 
enabling the reader to learn the very latest methods of investigation without 
consulting works specially devoted to the subject. 

CONTRIBUTORS : 



Dr. J. S. Billings, Philadelphia. 
Francis Delafield, New York. 
Reginald H. Fitz, Boston. 
James W. Holland, Philadelphia. 
Henry M. Lyman, Chicago. 
William Osier, Baltimore. 



Dr. William Pepper, Philadelphia. 
W. Gilman Thompson, New York. 
W. H. Welch, Baltimore. 
James T. Whittaker, Cincinnati. 
James C. Wilson, Philadelphia. 
Horatio C. Wood, Philadelphia. 



" We reviewed the first volume of this work, and said : ' It is undoubtedly one of the best 
text-books on the practice of medicine which we possess.' A consideration of the second 
and last volume leads us to modify that verdict and to say that the completed work is, in our 
opinion, the best of its kind it has ever been our fortune to see. It is complete, thorough, 
accurate, and clear. It is well written, well arranged, well printed, well illustrated, and well 
bound. It is a model of what the modern text-book should be." — New York Medical Journal. 

" A library upon modern medical art. The work must promote the wider diffusion of 
sound knowledge." — American Lancet. 

" A trutty counsellor for the practitioner or senior student, on which he may implicitly 
rely." — Edinburgh Medical Journal. 



CATALOGUE OF MEDICAL WORKS. 



*AN AMERICAN TEXT-BOOK OF SURGERY. Edited by Wil- 
liam W. Keen, M.D., LL.D., and J. William White, M. D., Ph. D. 
Forming one handsome royal octavo volume of 1230 pages (10 x 7 inches), 
with 496 wood-cuts in text, and $7 colored and half-tone plates, many of 
them engraved from original photographs and drawings furnished by the 
authors. Price : Cloth, 57. 00 net; Sheep or Half Morocco, SS.00 net. 

THIRD EDITION, THOROUGHLY REVISED. 

The want of a text-book which could be used by the practitioner and at the 
same time be recommended to the medical student has been deeply felt, espe- 
cially by teachers of surgery; hence, when it was suggested to a num6er of 
these that it would be well to unite in preparing a text-book of this description, 
great unanimity of opinion was found to exist, and the gentlemen below named 
gladly consented to join in its production. While there is no distinctive Amer- 
ican Surgery, yet America has contributed very largely to the progress of modern 
surgery, and among the foremost of those who have aided in developing this art 
and science will be found the authors of the present volume. All of tbem are 
teachers of surgery in leading medical schools and hospitals in the United States 
and Canada. 

Especial prominence has been given to Surgical Bacteriology, a feature which 
is believed to be unique in a surgical text-book in the English language. Asep- 
sis and Antisepsis have received particular attention. The text is brought well 
up to date in such important branches as cerebral, spinal, intestinal, and pelvic 
surgery, the most important and newest operations in these departments being 
described and illustrated. 

The text of the entire book has been submitted to all the authors for their 
mutual criticism and revision — an idea in book- making that is entirely new and 
original. The book as a whole, therefore, expresses on all the important sur- 
gical topics of the day the consensus of opinion of the eminent surgeons who 
have joined in its preparation. 

One of the most attractive features of the book is its illustrations. Very 
many of them are original and faithful reproductions of photographs taken 
directly from patients or from specimens. 



CONTRIBUTORS 



Dr. Phineas S. Conner, Cincinnati. 
Frederic S. Dennis, New York. 
William W. Keen, Philadelphia. 
Charles B. Nancrede, Ann Arbor. Mich. 
Roswell Park, Buffalo, New York. 
Lewis S. Pilcher. New York. 

" If this text-book is a fai 



Dr. Nicholas Senn, Chicago. 

Francis J. Shepherd, Montreal, Canada. 

Lewis A. Slimson, New York. 

J. Collins Warren, Boston. 

J. William White, Philadelphia. 



ur reflex of the present position of American surgery, we must 
admit it is of a very high order of merit, and that English surgeons will have to look very 
carefully to their laurels if they are to preserve a position in the van of surgical practice "— 
Londo)r Lancet. r 



IO W. B. SAUNDERS' 



UN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL 
AND SURGICAL, for the use of Students and Practitioners. 

Edited by J. M. Baldy, M. D. Forming a handsome royal-octavo volume 
of 718 pages, with 341 illustrations in the text and 38 colored and half- 
tone plates. Prices : Cloth, $6.00 net; Sheep or Half-Morocco, $7.00 net. 

SECOND EDITION, THOROUGHLY REVISED. 

In this volume all anatomical descriptions, excepting those essential to a clear 
understanding of the text, have been omitted, the illustrations being largely de- 
pended upon to elucidate the anatomy of the parts. This work, which is 
thoroughly practical in its teachings, is intended, as its title implies, to be a 
working text-book for physicians and students. A clear line of treatment has 
been laid down in every case, and although no attempt has been made to dis- 
cuss mooted points, still the most important of these have been noted and ex- 
plained. The operations recommended are fully illustrated, so that the reader, 
having a picture of the procedure described in the text under his eye, cannot fail 
to grasp the idea. All extraneous matter and discussions have been carefully 
excluded, the attempt being made to allow no unnecessary details to cumber 
the text. The subject-matter is brought up to date at every point, and the 
work is as nearly as possible the combined opinions of the ten specialists who 
figure as the authors. 

In the revised edition much new material has been added, and some of the 
old eliminated or modified. More than forty of the old illustrations have been 
replaced by new ones, which add very materially to the elucidation of the 
text, as they picture methods, not specimens. The chapters on technique and 
after-treatment have been considerably enlarged, and the portions devoted to 
plastic work have been so greatly improved as to be practically new. Hyste- 
rectomy has been rewritten, and all the descriptions of operative procedures 
have been carefully revised and fully illustrated. 



CONTRIBUTORS : 



Dr. Henry T. Byford. 
John M. Baldy. 
Edwin Cragin. 
J. H. Etheridge. 
William Goodell. 



Dr. Howard A. Kelly. 
Florian Krug. 
E. E. Montgomery. 
William R. Pryor. 
George M. Tuttle. 



"The most notable contribution to gynecological literature since 1887, .... and the most 
complete exponent of gynecology which we have. No subject seems to have been neglected, 
.... and the gynecologist and surgeon,, and the general practitioner who has any desire 
to practise diseases of women, will find it of practical value. In the matter of illustrations 
and plates the book surpasses anything we have seen." — Boston Medical and Surgical 
Journal. 

" A thoroughly modern text-book, and gives reliable and well-tempered advice and in- 
struction." — Edinburgh Medical Journal. 

" The harmony of its conclusions and the homogeneity of its style give it an individuality 
which suggests a single rather than a multiple authorship." — Annals of Surgery. 

'* It must command attention and respect as a worthy representation of our advanced 
clinical teaching." — American Journal of Medical Sciences. 



CATALOGUE OF MEDICAL WORKS. 



It 



*AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL- 
DREN. By American Teachers. Edited by Louis Starr, M. D., 
assisted by Thompson S. Westcott, M. D. In one handsome royal-8vo 
volume of 1 244 pages, profusely illustrated with wood-cuts, half-tone and 
colored plates. Net Prices: Cloth, $7.00; Sheep or Half-Morocco, $8.00. 

SECOND EDITION, REVISED AND ENLARGED. 

The plan of this work embraces a series of original articles written by some 
sixty well-known podiatrists, representing collectively the teachings of the most 
prominent medical schools and colleges of America. The work is intended to 
be a practical book, suitable for constant and handy reference by the practi- 
tioner and the advanced student. 

Especial attention has been given to the latest accepted teachings upon the 
etiology, symptoms, pathology, diagnosis, and treatment of the disorders of chil- 
dren, with the introduction of many special formulae and therapeutic procedures. 

In this new edition the whole subject matter has been carefully revised, new 
articles added, some original papers emended, and a number entirely rewritten. 
The new articles include "Modified Milk and Percentage Milk-Mixtures," 
" Lithemia," and a section on " Orthopedics." Those rewritten are " Typhoid 
Fever," "Rubella," "Chicken-pox," "Tuberculous Meningitis," "Hydroceph- 
alus," and "Scurvy;" while extensive revision has been made in "Infant 
Feeding," " Measles," " Diphtheria," and " Cretinism." The volume has thus 
been much increased in size by the introduction of fresh material. 



Dr. 



CONTRIBUTORS : 



S. S. Adams, Washington. 
John Ashhurst, Jr., Philadelphia. 
A. D. Blackader, Montreal, Canada. 
David Bovaird, New York. 
Dillon Brown, New York. 
Edward M. Buckingham, Boston. 
Charles \V. Burr, Philadelphia. 
W. E. Casselberry, Chicago. 
Henry Dwight Chapin, New York. 
W. S. Christopher, Chicago. 
Archibald Church, Chicago. 
Floyd M. Crandall, New York. 
Andrew F. Currier, New York. 
Roland G. Curtin, Philadelphia 
J. M. DaCosta, Philadelphia. 
I. N. Danforth, Chicago. 
Edward P. Davis, Philadelphia. 
John B. Deaver, Philadelphia. 
G. E. de Schweinitz, Philadelphia. 
John Doming, New York. 
Charles Warrington Earle, Chicago. 
Wm. A. Edwards, San Diego, Cal. 
F. Forchheimer, Cincinnati. 
J. Henry Fruitnight, New York. 
J. P. Crozer Griffith, Philadelphia. 
W. A. Hardaway. St. Louis. 
M. P Hatfield, Chicago. 
Barton Cooke Hirst, Philadelphia. 
H. Illoway, Cincinnati. 
Henry Jackson, Boston. 
Charles G. Jennings, Detroit. 
Henry Koplik. New York. 



Dr. Thomas S. Latimer, Baltimore. 

Albert R. Leeds, Hoboken, N. J. 

J. Hendrie Lloyd, Philadelphia. 

George Roe Lockwood, New York. 

Henry M. Lyman, Chicago. 

Francis T. Miles, Baltimore. 

Charles K Mills, Philadelphia. 

James E. Moore, Minneapolis. 

F. Gordon Morrill, Boston. 

John H. Musser, Philadelphia. 

Thomas R. Neilson, Philadelphia, 

W. P. Northrup, New York. 

William Osier, Baltimore. 

Frederick A. Packard, Philadelphia. 

William Pepper, Philadelphia. 

Frederick Peterson, New York. 

W. T. Plant, Syracuse, New York. 

William M. Powell. Atlantic City. 

B. K. Rachford, Cincinnati. 

B. Alexander Randall, Philadelphia. 

Edward O. Shakespeare, Philadelphia 

F. C. Shattuck, Boston. 

J. Lewis Smith, New York. 

Louis Starr, Philadelphia. 

M. Allen Starr, New York. 

Charles W. Townsend, Boston. 

James Tyson, Philadelphia. 

W. S. Thayer, Baltimore. 

Victor C. Vaughan, Ann Arbor, Mich 

Thompson S. Westcott, Philadelphia. 

Henry R. Wharton, Philadelphia. 

J. William White, Philadelphia. 

I C. Wilson, Philadelphia. 



12 



W. B. SAUNDERS 



*AN AMERICAN TEXT-BOOK OF GENITO-URINARY AND 
SKIN DISEASES. By 47 Eminent Specialists and Teachers. Edited 
by L. Bolton Bangs, M. D., Professor of Genito-Urinary Surgery, Uni- 
versity and Bellevue Hospital Medical College, New York; and W. A. 
Hardaway, M. D., Professor of Diseases of the Skin, Missouri Medical 
College. Imperial octavo volume of 1229 pages, with 300 engravings and 
20 full-page colored plates. Cloth, #7.00 net; Sheep or Half Morocco, 
$8.00 net. 

This addition to the series of " American Text-Books," it is confidently be- 
lieved, will meet the requirements of both students and practitioners, giving, as 
it does, a comprehensive and detailed presentation of the Diseases of the 
Genito-Urinary Organs, of the Venereal Diseases, and of the Affections of the 
Skin. 

Having secured the collaboration of well-known authorities in the branches 
represented in the undertaking, the editors have not restricted the contributors 
it. regard to the particular views set forth, but have offered every facility for the 
free expression of their individual opinions. The work will therefore be found 
to be original, yet homogeneous and fully representative of the several depart- 
ments of medical science with which it is concerned. 



CONTRIBUTORS : 



Dr. Chas. W. Allen, New York. 
I. E. Atkinson, Baltimore. 
L Bolton Bangs, New York. 
P. R. Bolton, New York. 
Lewis C. Bosher, Richmond, Va. 
John T. Bowen, Boston. 
J. Abbott-Cantrell, Philadelphia. 
William T. Corlett, Cleveland, Ohio. 
B. Farquhar Curtis, New York. 
Condict W. Cutler, New York. 
Isadore Dyer, New Orleans. 
Christian Fenger, Chicago. 
John A. Fordyce, New York. 
Eugene Fuller, New York. 
R. H. Greene, New York. 
Joseph Grindon, St. Louis. 
Graeme M. Hammond, New York. 
W. A. Hardaway, St. Louis. 
M. B. Hartzell, Philadelphia. 
Louis Heitzmann, New York. 
James S. Howe, Boston. 
George T. Jackson, New York. - 
Abraham Jacobi, New York. 
James C. Johnston, New York. 



Dr. Hermann G. Klotz, New York. 
J. H. Linsley, Burlington, Vt. 
G. F. Lydston, Chicago. 
Hartwell N. Lyon, St. Louis. 
Edward Martin, Philadelphia. 
D. G. Montgomery, San Francisco. 
James Pedersen, New York. 
S. Pollitzer, New York. 
Thomas R. Pooley, New York. 
A. R. Robinson, New York. 
A. E. Rtgensburger, San Francisco. 
Francis J. Shepherd, Montreal, Can. 
S. C. Stanton, Chicago, 111. 
Emmanuel J. Stout, Philadelphia. 
Alonzo E. Taylor Philadelphia. 
Robert W. Taylor, New York. 
Paul Thorndike, Boston. 
H. Tuholske, St. Louis. 
Arthur Van Harlingen, Philadelphia. 
Francis S. Watson, Boston. 
J. William White, Philadelphia. 
J. McF. Winfield, Brooklyn. 
Alfred C. Wood, Philadelphia. 



"This voluminous work is thoroughly up to date, and the chapters on genito-urinary dis- 
eases are especially valuable. The illustrations are fine and are mostly original. The section 
on dermatology is concise and in every way admirable."— Journal of the American Medical 
Association. 

"This volume is one of the best yet issued of the publisher's series of 'American Text- 
Books.' The list of contributors represents an extraordinary array of talent and extended 
experience. The book will easily take the place in comprehensiveness and value of the 
half dozen or more costly works on these subjects which have hitherto been necessary to a 
well-equipped library." — New York Polyclinic. 



CATALOGUE OF MEDICAL WORKS. 



13 



* AN AMERICAN TEXT-BOOK OF DISEASES OF THE EYE, 
EAR, NOSE, AND THROAT. Edited by George E. de Schweinitz, 

A. M., M. D., Professor of Ophthalmology, Jefferson Medical College ; and 

B. Alexander Randall, A. M., M. D., Clinical Professor of Diseases of 
the Ear, University of Pennsylvania. One handsome imperial octavo 
volume of 1251 pages; 766 illustrations, 59 of them colored. Prices: 
Cloth, $7.00 net; Sheep or Half- Morocco, $8.00 net. 

Just Issued. 

The present work is the only book ever published embracing diseases of the 
intimately related organs of the eye, ear, nose, and throat. Its special claim 
to favor is based on encyclopedic, authoritative, and practical treatment of the 
subjects. 

Each section of the' book has been entrusted to an author who is specially 
identified with the subject on which he writes, and who therefore presents his 
case in the manner of an expert. Uniformity is secured and overlapping pre- 
vented by careful editing and by a system of cross-references which forms a 
special feature of the volume, enabling the reader to come into touch with all 
that is said on any subject in different portions of the book. 

Particular emphasis is laid on the most approved methods of treatment, so 
that the book shall be one to which the student and practitioner can refer for 
information in practical Work. Anatomical and physiological problems, also, 
are fully discussed for the benefit of those who desire to investigate the more 
abstruse problems of the subject. 



CONTRIBUTORS : 



Dr. Henry A. Alderton, Brooklyn. 
Harrison Allen, Philadelphia. 
Frank Allport, Chicago. 
Morris J. Asch, New York. 
S. C. Ayres, Cincinnati. 
R. O. Beard, Minneapolis. 
Clarence J. Blake, Boston. 
Arthur A. Bliss, Philadelphia. 
Albert P. Brubaker, Philadelphia. 
J. H. Bryan, Washington, D. C. 
Albert H. Buck, New York. 
F. Buller, Montreal, Can. 
Swan M. Burnett, Washington, D. C. 
Flemming Carrow, Ann Arbor, Mich. 
W. E. Casselberry, Chicago. 
Colman W. Cutler, New York. 
Edward B. Dench, New York. 
William S. Dennett, New York. 
George E. de Schweinitz, Philadelphia 
Alexander Duane, New York. 
John W. Farlow, Boston, Mass. 
Walter J. Freeman, Philadelphia. 
H. Gifford, Omaha, Neb. 
W. C. Glasgow, St. Louis. 
J. Orne Green, Boston. 
Ward A. Holden, New York. 
Christian R. Holmes, Cincinnati. 
William E. Hopkins, San Francisco. 
F. C. Hotz, Chicago. 
Lucien Howe, Buffalo, N. Y. 



Dr. Alvin A. Hubbell, Buffalo, N. Y. 
Edward Jackson, Philadelphia. 
J. Ellis Jennings, St. Louis. 
Herman Knapp, New York. 
Chas. W. Kollock, Charleston, S. C. 
G. A. Leland, Boston. 
J. A. Lippincott, Pittsburg, Pa. 
G. Hudson Makuen, Philadelphia. 
John H. McCollom, Boston. 
H. G. Miller, Providence, R. I. 
B. L. Milliken, Cleveland, Ohio. 
Robert C. Myles, New York. 
James E. Newcomb, New York. 
R. J. Phillips, Philadelphia. 
George A. Piersol, Philadelphia. 
W. P. Porcher, Charleston, S. C. 
B. Alex. Randall, Philadelphia. 
Robert L. Randolph, Baltimore. 
John O. Roe, Rochester, N. Y. 
Charles E. de M. Sajous, Philadelphia. 
J. E. Sheppard, Brooklyn, N. Y. 
E. L. Shurly, Detroit, Mich. 
William M. Sweet, Philadelphia. 
Samuel Theobald, Baltimore, Md. 
A. G. Thomson, Philadelphia. 
Clarence A. Veasey, Philadelphia. 
John E. Weeks, New York. 
Casey A. Wood, Chicago, 111. 
Jonathan Wright, Brooklyn. 
H. V. Wiirdemann, Milwaukee, Wis. 



14 



W. B. SAUNDERS' 



*AN AMERICAN YEAR-BOOK OF MEDICINE AND SUR- 
GERY. A Yearly Digest of Scientific Progress and Authoritative 
Opinion in all branches of Medicine and Surgery, drawn from journals, 
monographs, and text-books of the leading American and Foreign authors 
and investigators. Collected and arranged, with critical editorial com- 
ments, by eminent American specialists and teachers, under the general 
editorial charge of George M. Gould, M.D. One handsome imperial 
octavo volume of about 1200 pages. Uniform in style, size, and general 
make-up with the "American Text-Book" Series. Cloth, $6.50 net; 
Half- Morocco, #7.50 net. 

Now Beady, Volumes for 1896, 1897, 1898, 1899. 

Notwithstanding the rapid multiplication of medical and surgical works, still 
these publications fail to meet fully the requirements of the general physician, 
inasmuch as he feels the need of something more than mere text-books of well- 
known principles of medical science. 

This deficiency would best be met by current journalistic literature, but most 
practitioners have scant access to this almost unlimited source of information, 
and the busy practiser has but little time to search out in periodicals the many 
interesting cases whose study would doubtless be of inestimable value in his 
practice. Therefore, a work which places before the physician in convenient 
form an epitomization of this literature by persons competent to pronounce upon 

The Value of a Discovery or of a Method of Treatment 

cannot but command his highest appreciation. It is this critical and judicial 
function that is assumed by the Editorial staff of the " American Year-Book 
of Medicine and Surgery." 



CONTRIBUTORS 



Dr. Samuel W. Abbott. Boston. 
John J. Abel, Baltimore. 
J. M. Baldy, Philadelphia. 
Charles H. Burnett, Philadelphia. 
Archibald Church, Chicago. 
J. Chalmers DaCosta, Philadelphia. 
W. A. N. Dorland, Philadelphia. 
Louis A. Duhring, Philadelphia. 
D. L. Edsall, Philadelphia. 
Virgil P. Gibney, New York. 
Henry A. Griffin, New York. 
John Guiteras, Philadelphia. 
C. A. Hamann, Cleveland. 
Alfred Hand, Jr., Philadelphia. 



Dr. Howard E. Hansell, Philadelphia. 
M. B. Hartzell, Philadelphia. 
Barton Cooke Hirst, Philadelphia. 
E. Fletcher lngals, Chicago. 
Wyatt Johnston, Montreal. 
W. W. Keen, Philadelphia. 
Henry G. Ohls, Chicago. 
Wendell Reber, Philadelphia. 
David Riesman, Philadelphia. 
Louis Starr, Philadelphia. 
Alfred Stengel, Philadelphia. 
G. N. Stewart. Cleveland. 
J. R. Tillinghast, New York. 
J. Hilton Waterman, New York. 



" It is difficult to know which to admire most — the research and industry of the distin- 
guished band of experts whom Dr. Gould has enlisted in the service of the Year-Book, or the 
wealth and abundance of the contributions to every department of science that have been 
deemed worthy of analysis. ... It is much more than a mere compilation of abstracts, for, 
as each section is entrusted to experienced and able contributors, the reader has the advan- 
tage of certain critical commentaries and expositions . . . proceeding from writers fully 
qualified to perform these tasks. ... It is emphatically a book which should find a place in 
every medical library, and is in several respects more useful than the famous ' Jahrbucher' 
of Germany." — London Lancet. 



CATALOGUE OF MEDICAL WORKS. 1 5 

* ANOMALIES AND CURIOSITIES OF MEDICINE. By George 
M. Gould, M.D., and Walter L. Pyle, M.D. An encyclopedic collec- 
tion of are and extraordinary cases and of the most striking instances of 
abnormality in all branches of Medicine and Surgery, derived from an ex- 
haustive research of medical literature from its origin to the present day, 
abstracted, classified, annotated, and indexed. Handsome imperial octavo 
volume of 968 pages, with 295 engravings in the text, and 12 full-page 
plates. Cloth, $6.00 net; Half-Morocco, S7.00 net. 

Several years of exhaustive research have been spent by the authors in the 
great medical libraries of the United States and Europe in collecting the mate- 
rial for this work. Medical literature of all ages and all languages has 
been carefully searched, as a glance at the Bibliographic Index will show. The 
facts, which will be of extreme value to the author and lecturer, have been 
arranged and annotated, and full reference footnotes given, indicating whence 
they have been obtained. 

In view of the persistent and dominant interest in the anomalous and curious, 
a thorough and systematic collection of this kind (the first of which the 
authors have knowledge) must have its own peculiar sphere of usefulness. 

As a complete and authoritative Book of Reference it will be of value not 
only to members of the medical profession, but to all persons interested in gen- 
eral scientific, sociologic, and medico-legal topics ; in fact, the general interest 
of the subject and the dearth of any complete work upon it make this volume 
one of the most important literary innovations of the day. 

" One of the most valuable contributions ever made to medical literature. It is, so far as 
we know, absolutely unique, and every page is as fascinating as a novel. Not alone for the 
medical profession has this volume value : it will serve as a book of reference for all who are 
interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical yonr- 
nal. 



NERVOUS AND MENTAL DISEASES. By Archibald Church, 
M. D., Professor of Clinical Neurology, Mental Diseases, and Medical 
Jurisprudence, Northwestern University Medical School; and Frederick 
Peterson, M. D., Clinical Professor of Mental Diseases, Woman's Medi- 
cal College, New York. Handsome octavo volume of 843 pages, with 
over 300 illustration*. Prices: Cloth, S5.00 net; Half- Morocco, S6.00 
net. 

Just Issued. 

This book is intended to furnish students and practitioners with a practical, 
working knowledge of nervous and mental diseases. Written by men of wide 
experience and authority, it presents the many recent additions to the subject. 
The book is not filled with an extended dissertation on anatomy and pathology, 
but, treating these points in connection with special conditions, it lays particular 
stress on methods of examination, diagnosis, and treatment. In this respect the 
work is unusually complete and valuable, laying down the definite courses of 
procedure which the authors have found to be most generally satisfactory. 



1 6 W. B. SAUNDERS' 



A TEXT-BOOK OF PATHOLOGY. By Alfred Stengel, M. D., 
Professor of Clinical Medicine in the University of Pennsylvania; Physi- 
cian to the Philadelphia Hospital; Physician to the Children's Hospital, 
Philadelphia. Handsome octavo volume of 848 pages, with 362 illustra- 
tions, many of which are in colors. Prices : Cloth, $4.00 net ; Half- 
Morocco, $5.00 net. 

Second Edition. 

In this work the practical application of pathological facts to clinical medicine 
is considered more fully than is customary in works on pathology. While the 
subject of pathology is treated in the broadest way consistent with the size of 
the book, an effort has been made to present the subject from the point of view 
of the clinician. The general relations of bacteriology to pathology are dis- 
cussed at considerable length, as the importance of these branches deserves. It 
will be found that the recent knowledge is fully considered, as well as older and 
more widely-known facts. 

" I consider the work abreast of modern pathology, and useful to both students and prac- 
titioners. It presents in a concise and well-considered form the essential facts of general and 
special pathological anatomy, with more than usual emphasis upon pathological physiology." 
— William H. Welch, Professor of Pathology, Johns Hopkins University, Baltimore, Md. 
" I regard it as the most serviceable text-book for students on this subject yet written by 
an American author." — L. Hektoen, Professor of Pathology, Rush Medical College, 
Chicago, III. 

A TEXT-BOOK OF OBSTETRICS. By Barton Cooke Hirst, M.D., 
Professor of Obstetrics in the University of Pennsylvania. Handsome oc- 
tavo volume of 846 pages, with 618 illustrations and seven colored plates. 
Prices : Cloth, $5.00 net ; Half-Morocco, $6.00 net. 

This work, which has been in course of preparation for several years, is in- 
tended as an ideal text-book for the student no less than an advanced treatise 
for the obstetrician and for general practitioners. It represents the very latest 
teaching in the practice of obstetrics by a man of extended experience and 
recognized authority. The book emphasizes especially, as a work on obstetrics 
should, the practical side of the subject, and to this end presents an unusually 
large collection of illustrations. A great number of these are new and original, 
and the whole collection will form a complete atlas of obstetrical practice. 
An extremely valuable feature of the book is the large number of refer- 
ences to cases, authorities, sources, etc., forming, as it does, a valuable bib- 
liography of the most recent and authoritative literature on the subject 
of obstetrics. As already stated, this work records the wide practical ex- 
perience of the author, which fact, combined with the brilliant presentation 
of the subject, will doubtless render this one of the most notable books on 
obstetrics that has yet appeared. 

" The illustrations are numerous and are works of art, many of them appearing for the 
first time. The arrangement of the subject-matter, the foot-notes, and index are beyond 
criticism. The author's style, though condensed, is singularly clear, so that it is never 
necessary to re-read a sentence in order to grasp its meaning. As a true model of what a 
modern text-book in obstetrics should be, we feel justified in affirming that Dr. Hirst's 
book is without a rival." — New York Medical Record. 



CATALOGUE OF MEDICAL WORKS. \y 

A TEXT-BOOK OF THE PRACTICE OF MEDICINE. By 

James M. Anders, M.D., Ph.D., LL.D., Professor of the Practice of 
Medicine and of Clinical Medicine, Medico-Chirurgical College, Philadel- 
phia. In one handsome octavo volume of 1287 pages, fully illustrated. 
Cloth, $5.50 net; Sheep or Half-Morocco, $6.50 net. 

THIRD EDITION, THOROUGHLY REVISED. 

This work gives in a comprehensive manner the results of the latest scientific 
studies bearing upon medical affections, and portrays with rare force and clear- 
ness the clinical pictures of the different diseases considered. The practical 
points, particularly with reference to diagnosis and treatment, are completely 
stated and are presented in a most convenient form ; for example, the differ- 
ential diagnosis has in many instances been tabulated, no less than fifty-six 
diagnostic tables being given. 

The first edition of this work having been exhausted in so short a time, the 
author has not found it necessary to make an extensive revision, but has simply 
availed himself of the opportunity to make a few changes of minor importance. 

" It is an excellent book — concise, comprehensive, thorough, and up to date. It is a 
credit to you; but, more than that, it is a credit to the profession of Philadelphia — to us." 
— James C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jeffer- 
son Medical College, Philadelphia. 

'* I consider Dr. Anders' book not only the best late work on Medical Practice, but by far 
the best that has ever been published. It is concise, systematic, thorough, and fully up to 
date in everything. I consider it a great credit to both the author and the publisher." — A. 
C. Cowperthwaite, President of the Illinois Homeopathic Medical Association. 

DISEASES OF THE STOMACH. By William W. Van Valzah, 
M. D., Professor of General Medicine and Diseases of the Digestive System 
and the Blood, New York Polyclinic; and J. Douglas Nisbet, M. D., 
Adjunct Professor of General Medicine and Diseases of the Digestive Sys- 
tem and the Blood, New York Polyclinic. _ Octavo volume of 674 pages, 
illustrated. Cloth, $3.50 net. 

An eminently practical book, intended as a guide to the student, an aid to the 
physician, and a contribution to scientific medicine. It aims to give a complete 
description of the modern methods of diagnosis and treatment of diseases of the 
stomach, and to reconstruct the pathology of the stomach in keeping with the 
revelations of scientific research. The book is clear, practical, and complete, 
and contains the results of the authors' investigations and of their extensive ex- 
perience as specialists. Particular attention is given to the important subject of 
dietetic treatment. The diet-lists are very complete, and are so arranged that 
selections can readily be made to suit individual cases. 

" This is the most satisfactory work on the subject in the English language." — Chicago 
Medical Recorder. 

" The article on diet and general medication is one of the most valuable in the book, and 
should be read by every practising physician." — New York Medical Journal. 



1 8 IV. B. SAUNDERS' 

SURGICAL DIAGNOSIS AND TREATMENT. By J. W. Mac- 
donald, M. D., Edin., F. R. C.S., Edin., Professor of the Practice of Sur- 
gery and of Clinical Surgery in Hamline University ; Visiting Surgeon to St. 
Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 800 
pages, profusely illustrated. Cloth, -$5.00 net; Half- Morocco, $6.00 net. 
This work aims in a comprehensive manner to furnish a guide in matters of 
surgical diagnosis. It sets forth in a systematic way the necessities of examina- 
tions and the proper methods of making them. The various portions of the 
body are then taken up in order and the diseases and injuries thereof succinctly 
considered and the treatment briefly indicated. Practically all the modern and 
approved operations are described with thoroughness and clearness. The work 
concludes with a chapter on the use of the Rontgen rays in surgery. 

" The work is brimful of just the kind of practical information that is useful alike to 
students and practitioners. It is a pleasure to commend the book because of its intrinsic 
value to the medical practitioner." — Cincinnati Lancet- Clinic. 

PATHOLOGICAL TECHNIQUE. A Practical Manual for Laboratory 
Work in Pathology, Bacteriology, and Morbid Anatomy, with chapters on 
Post-Mortem Technique and the Performance of Autopsies. By Frank 
B. Mallory, A. M., M. D., Assistant Professor of Pathology, Harvard 
University Medical School, Boston ; and James H. Wright, A. M., M. D., 
Instructor in Pathology, Harvard University Medical School, Boston. Oc- 
tavo volume of 396 pages, handsomely illustrated. Cloth, $2.50 net. 

This book is designed especially for practical use in pathological laboratories, 

both as a guide to beginners and as a source of reference for the advanced. The 

book will also meet the wants of practitioners who have opportunity to do general 

pathological work. Besides the methods of post-mortem examinations and of 

bacteriological and histological investigations connected with autopsies, the 

special methods employed in clinical bacteriology and pathology have been 

fully discussed. 

" One of the most complete works on the subject, and one which should be in the library 
of every physician who hopes to keep pace with the great advances made in pathology." — 
yournal of American Medical Association. 

THE SURGICAL COMPLICATIONS AND SEQUELS OF TY- 
PHOID FEVER. By Wm. W. Keen, M. D., LL.D., Professor of the 
Principles of Surgery and of Clinical Surgery, Jefferson Medical College, 
Philadelphia. Octavo volume of 386 pages, illustrated. Cloth, $3.00 net. 

This monograph is the only one in any language covering the entire subject 
of the Surgical Complications and Sequels of Typhoid Fever. The work will 
prove to be of importance and interest not only to the general surgeon and phy- 
sician, but also to many specialists — laryngologists, ophthalmologists, gynecolo- 
gists, pathologists, and bacteriologists — as the subject has an important bearing 
upon each one of their spheres. The author's conclusions are based on reports 
of over 1700 cases, including practically all those recorded in tire last fifty years. 
Reports of cases have been brought down to date, many having been added 
while the work was in press. 

" This is probably the first and only work in the English language that gives the reader a 
clear view of what typhoid fever really is, and what it does and can do to the human organ- 
ism. This book should be in the possession of every medical man in America." — American 
Medico-Surgical Bulletin. 



CATALOGUE OF MEDICAL WORKS. 19 



MODERN SURGERY, GENERAL AND OPERATIVE. By John 
Chalmers DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medi- 
cal College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. 
Handsome octavo volume of 911 pages, profusely illustrated. Cloth, $4.00 
net ; Half- Morocco, $5.00 net. 

Second Edition, Rewritten and Greatly Enlarged. 

The remarkable success attending DaCosta's Manual of Surgery, and the 
general favor with which it has been received, have led the author in this 
revision to produce a complete treatise on modern surgery along the same lines 
that made the former edition so successful. The book has been entirely re- 
written and very much enlarged. The old edition has long been a favorite not 
only with students and teachers, but also with practising physicians and sur- 
geons, and it is believed that the present work will find an even wider field of 
usefulness. 

" We know of no small work on surgery in the English language which so well fulfils the 
requirements of the modern student." — Medico-Chirurgical Journal, Bristol, England. 

" The author has presented concisely and accurately the principles of modern surgery. 
The book is a valuable one which can be recommended to students and is of great value to 
the general practitioner." — American Journal of the Medical Sciences. 

A MANUAL OF ORTHOPEDIC SURGERY. By James E. Moore, 
M.D., Professor of Orthopedics and Adjunct Professor of Clinical Surgery, 
University of Minnesota, College of Medicine and Surgery. Octavo volume 
of 356 pages, with 177 beautiful illustrations from photographs made spec- 
ially for this work. Cloth, $2.50 net. 

A practical book based upon the author's experience, in which special stress 
is laid upon early diagnosis and treatment such as can be carried out by the 
general practitioner. The teachings of the author are in accordance with his 
belief that true conservatism is to be found in the middle course between the 
surgeon who operates too frequently and the orthopedist who seldom operates. 

" A very demonstrative work, every illustration of which conveys a lesson. The work is 
a most excellent and commendable one, which we can certainly endorse with pleasure." — 
St. Louis Medical and Surgical Journal. 

ELEMENTARY BANDAGING AND SURGICAL DRESSING. 

With Directions concerning the Immediate Treatment of Cases of Emer- 
gency. For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., 
late Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80 
illustrations. Cloth, flexible covers, 75 cents net. 

This little book is chiefly a condensation of those portions of Pye's " Surgical 
Handicraft" which deal with bandaging, splinting, etc., and of those which 
treat of the management in the first instance of cases of emergency. The 
directions given are thoroughly practical, and the book will prove extremely use- 
ful to students, surgical nurses, and dressers. 

"The author writes well, the diagrams are clear, and the book itself is small and portable, 
although the paper and type are good." — British Medical Journal. 



20 W. B. SAUNDERS' 



A TEXT-BOOK OF MATERIA MEDICA, THERAPEUTICS 
AND PHARMACOLOGY. By George F. Butler, Ph.G., M.D., 
Professor of Materia Medica and of Clinical Medicine in the College of 
Physicians and Surgeons, Chicago; Professor of Materia Medica and 
Therapeutics, Northwestern University, Woman's Medical School, etc 
Octavo, 860 pages, illustrated. Cloth, $4.00 net; Sheep, $5.00 net. 
Third Edition, Thoroughly Revised. 
A clear, concise, and practical text-book, adapted for permanent reference no 
less than for the requirements of the class-room. 

The recent important additions made to our knowledge of the physiological 
action of drugs are fully discussed in the present edition. Many alterations also 
have been made in the chapters on Diuretics and Cathartics. 

" Taken as a whole, the book may fairly be considered as one of the most satisfactory of any 
single-volume works on materia medica in the market."— -Journal of the American Medical 
Association. 

TUBERCULOSIS OF THE GENITO-URINARY ORGANS, 
MALE AND FEMALE. By Nicholas Senn, M.D., Ph.D., LL.D., 
Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical 
College, Chicago. Handsome octavo volume of 320 pages, illustrated # 
Cloth, $3.00 net. 
Tuberculosis of the male and female genito-urinary organs is such a frequent, 
distressing, and fatal affection that a special treatise on the subject appears to 
fill a gap in medical literature. In the present work the bacteriology of the sub- 
ject has received due attention, the modern resources employed in the differen- 
tial diagnosis between tubercular and other inflammatory affections are fully 
described, and the medical and surgical therapeutics are discussed in detail. 

"An important book upon an important subject, and written by a man of mature judg- 
ment and wide experience. The author has given us an instructive book upon one of the 
most important subjects of the day." — Clinical Reporter. 

"A work which adds another to the many obligations the profession owes the talented 
author." — Chicago Medical Recorder. 

A TEXT-BOOK OF DISEASES OF WOMEN. By Charles B. 
Penrose, M.D.^ Ph.D., Professor of Gynecology in the University of 
Pennsylvania; Surgeon to the Gynecean Hospital, Philadelphia. Octavo 
volume of 529 pages, with 217 illustrations, nearly all from drawings made 
for this work. Cloth, $3.50 net 

Second Edition, Revised. 
In this work, which has been written for both the student of gynecology and 
the general practitioner, the author presents the best teaching of modern gyne- 
cology untrammelled by antiquated theories or methods of treatment. In most 
instances but one plan of treatment is recommended, to avoid confusing the 
student or the physician who consults the book for practical guidance. 

" I shall value very highly the copy of Penrose's ' Diseases of Women' received. I have 
already recommended it to my class as THE BEST book."— Howard A. Kelly, Professor 
of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md. 

" The book is to be commended without reserve, not only to the student but to the general 
practitioner who wishes to have the latest and best modes of treatment explained with absolute 
clearness." — Therapeutic Gazette. 



CATALOGUE OF MEDICAL WORKS. 21 

SURGICAL PATHOLOGY AND THERAPEUTICS. By John 
Collins Warren, M. D., LL.D., Professor of Surgery, Medical Depart- 
ment Harvard University; Surgeon to the Massachusetts* General Hospital, 
etc. A handsome octavo volume of 832 pages, with 136 relief and litho- 
graphic illustrations, 33 of which are printed in colors, and all of which 
were drawn by William J. Kaula from original specimens. Prices : Cloth, 
$6.00 net; Half-Morocco, $7.00 net. 

Without Exception, the Illustrations are the Best ever Seen in a 

Work of this Kind. 

"A most striking and very excellent feature of this book is its illustrations. Without ex- 
ception, from the point of accuracy and artistic merit, they are the best ever seen in a work 
of this kind. * * * Many of those representing microscopic pictures are so perfect in their 
coloring and detail as almost to give the beholder the impression that he is looking down the 
barrel of a microscope at a well-mounted section." — Annals of Surgery, Philadelphia. 

" It is the handsomest specimen of book-making * * * that has ever been issued from the 
American medical press." — American Journal of the Medical Sciences, Philadelphia. 

PATHOLOGY AND SURGICAL TREATMENT OF TUMORS. 

By N. Senn, M. D., Ph. D., LL. D., Professor of Practice of Surgery and 
of Clinical Surgery, Rush Medical College ; Professor of Surgery, Chicago 
Polyclinic ; Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, 
St. Joseph's Hospital, Chicago. One volume of 710 pages, with 515 
engravings, including full-page colored plates. Prices: Cloth, $6.00 net; 
Half- Morocco, $7.00 net. 

Books specially devoted to this subject are few, and in our text-books and 
systems of surgery this part of surgical pathology is usually condensed to a de- 
gree incompatible with its scientific and clinical importance. The author spent 
many years in collecting the material for this work, and has taken great pains 
to present it in a manner that should prove useful as a text-book for the student, 
a work of reference for the practitioner, and a reliable guide for the surgeon. 

" The most exhaustive of any recent book in English on this subject. It is well illus- 
trated, and will doubtless remain as the principal monograph on the subject in our language 
for some years. The book is handsomely illustrated and printed, .... and the author has 
given a notable and lasting contribution to surgery." — fournal of the American Medical 
Association, Chicago. 

LECTURES ON RENAL AND URINARY DISEASES. By 

Robert Saundby, M. D., Edin., Fellow of the Royal College of Physicians, 
London, and of the Royal Medico-Chirurgical Society; Physician to the 
General Hospital. Octavo volume of 434 pages, with numerous illustra- 
tions and 4 colored plates. Cloth, $2.50 net. 

"The volume makes a favorable impression at once. The style is clear and succinct. 
We cannot find any part of the subject in which the views expressed are not carefully thought 
out and fortified by evidence drawn from the most recent sources. The book maybe cordially 
recommended." — British Medical fournal. 

" The work represents the present knowledge of renal and urinary diseases. It is ad- 
mirably written and is accurately scientific." — Medical News. 



22 W. B. SAUNDERS' 



NEW PRONOUNCING DICTIONARY OF MEDICINE, with 
Phonetic Pronunciation, Accentuation, Etymology, etc. By John 
M. Keating, M. D., LL.D., Fellow of the College of Physicians of Phila- 
delphia ; Vice-President of the American Pediatric Society ; Ex-President 
of the Association of Life Insurance Medical Directors ; Editor " Cyclo- 
paedia of the Diseases of Children," etc. ; and Henry Hamilton, author 
of " A New Translation of Virgil's ^Eneid into English Rhyme ;" co- 
author of "Saunders' Medical Lexicon," etc.; with the Collaboration of 
J. Chalmers DaCosta, M. D., and Frederick A. Packard, M. D. 
With an Appendix containing important Tables of Bacilli, Micrococci, 
Leucoma'ines, Ptomaines, Drugs and Materials used in Antiseptic Sur- 
gery, Poisqns and their Antidotes, Weights and Measures, Thermometric 
Scales, New Official and Unofficial Drugs, etc. One very attractive volume 
of over 800 pages. Second Revised Edition. Prices: Cloth, $5.00 net ; 
Sheep or Half-Morocco, $6.00 net; with Denison's Patent Ready-Refer- 
ence Index ; without patent index, Cloth, $4.00 net ; Sheep or Half- 
Morocco, $5.00. net. 



PROFESSIONAL OPINIONS. 

" I am much pleased with Keating's Dictionary, and shall take pleasure in recommending 
it to my classes." 

Henry M. Lyman, M. D., 
Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, III. 

" I am convinced that it will be a very valuable adjunct to my study-table, convenient in 
size and sufficiently full for ordinary use." 

C. A. LlNDSLEY, M. D., 

Professor of Theory and Practice of Medicine, Medical DeJ>t. Yale University : 

Secretary Connecticut State Board of Health, New Haven, Conn^ 



AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus Pro- 
fessor of Surgery in the Jefferson Medical College of Philadelphia, with 
Reminiscences of His Times and Contemporaries. Edited by his sons, 
Samuel W. Gross, M. D., LL.D., late Professor of Principles of Surgery 
and of Clinical Surgery in the Jefferson Medical College, and A. Haller 
Gross, A. M., of the Philadelphia Bar. Preceded by a Memoir of Dr. 
Gross, by the late Austin Flint, M. D., LL.D. In two handsome volumes, 
each containing over 400 pages, demy 8vo, extra cloth, gilt tops, with fine 
Frontispiece engraved on steel. Price per Volume, $2.50 net. 
This autobiography, which was continued by the late eminent surgeon until 
within three months of his death, contains a full and accurate history of his 
early struggles, trials, and subsequent successes, told in a singularly interesting 
and charming manner, and embraces short and graphic pen-portraits of many 
of the most distinguished men — surgeons, physicians, divines, lawyers, states- 
men, scientists, etc. — with whom he was brought in contact in America and in 
Europe ; the whole forming a retrospect of more than three-quarters of a century. 



CATALOGUE OF MEDICAL WORKS. 23 

PRACTICAL POINTS IN NURSING. For Nurses in Private' 
Practice. By Emily A. M. Stoney, Graduate of the Training-School 
for Nurses, Lawrence, Mass. ; Superintendent of the Training-School for 
Nurses, Carney Hospital, South Boston, Mass. 456 pages, handsomely 
illustrated with 73 engravings in the text, and 9 colored and half-tone 
plates. Cloth. Price, $1.75 net. 

SECOND EDITION, THOROUGHLY REVISED. 

In this volume the author explains, in popular language and in the shortest 
possible form, the entire range of private, nursing as distinguished from hospital 
nursing, and the nurse is instructed how best to meet the various emergencies of 
medical and surgical cases when distant from medical or surgical aid or when 
thrown on her own resources. 

An especially valuable feature of the work will be found in the directions to 
the nurse how to improvise everything ordinarily needed in the sick-room, where 
the embarrassment of the nurse, owing to the want of proper appliances, is fre- 
quently extreme. 

The work has been logically divided into the following sections : 

I. The Nurse : her responsibilities, qualifications, equipment, etc. 
II. The Sick- Room : its selection, preparation, and management. 

III. The Patient : duties of the nurse in medical, surgical, obstetric, and gyne- 

cologic cases. 

IV. Nursing in Accidents and Emergencies. 
V. Nursing in Special Medical Cases. 

VI. Nursing of the New-born and Sick Children. 
VII. Physiology and Descriptive Anatomy. 

The Appendix contains much information in compact form that will be found 
of great value to the nurse, including Rules for Feeding the Sick ; Recipes for 
Invalid Foods and Beverages ; Tables of Weights and Measures ; Table for 
Computing the Date of Labor ; List of Abbreviations ; Dose-List ; and a full 
and complete Glossary of Medical Terms and Nursing Treatment. 

"This is a well -written, eminently practical volume, which covers the entire range of 
private nursing as distinguished from hospital nursing, and instructs the nurse how best to 
meet the various emergencies which may arise and how to prepare everything ordinarily 
needed in the illness of her patient." — American Journal of Obstetrics and Diseases of 
Women and Children, Aug., 1896. 

A TEXT-BOOK OF BACTERIOLOGY, including the Etiology and 
Prevention of Infective Diseases and an account of Yeasts and Moulds, 
Haematozoa, and Psorosperms. By Edgar M. Crookshank, M. B., Pro- 
fessor of Comparative Pathology and Bacteriology, King's College, London. 
A handsome octavo volume of 700 pages, with 273 engravings in the text, 
and 22 original and colored plates. Price, $6.50 net. 

This book, though nominally a Fourth Edition of Professor Crookshank's 
" Manual of Bacteriology," is practically a new work, the old one having 
been reconstructed, greatly enlarged, revised throughout, and largely rewritten, 
forming a text-book for the Bacteriological Laboratory, for Medical Officers of 
Health, and for Veterinary Inspectors. 



24 W. B. SAUNDERS' 

MEDICAL DIAGNOSIS. By Dr. Oswald Vierordt, Professor of 
Medicine at the University of Heidelberg. Translated, with additions, 
from the Fifth Enlarged German Edition, with the author's permission, by 
Francis H. Stuart, A. M., M. D. In one handsome royal-octavo volume 
of 600 pages. 194 fine wood-cuts in the text, many of them in colors. 
Prices: Cloth, $4.00 net; Sheep or Half-Morocco, $5.00 net. 

FOURTH AMERICAN EDITION, FROM THE FIFTH REVISED AND 
ENLARGED GERMAN EDITION. 

In this work, as in no other hitherto published, are given full and accurate 
explanations of the phenomena observed at the bedside. It is distinctly a clin- 
ical work by a master teacher, characterized by thoroughness, fulness, and accu- 
racy. It is a mine of information upon the points that are so often passed over 
without explanation. Especial attention has been given to the germ-theory as a 
factor in the origin of disease. 

The present edition of this highly successful work has been translated from 
the fifth German edition. Many alterations have been made throughout the 
book, but especially in the sections on Gastric Digestion and the Nervous System. 

It will be found that all the qualities which served to make the earlier editions 
so acceptable have been developed with the evolution of the work to its present 
form. 

THE PICTORIAL ATLAS OF SKIN DISEASES AND SYPHI- 
LITIC AFFECTIONS. (American Edition.) Translation from 
the French. Edited by J. J. Pringle, M. B., F. R. C. P., Assistant Phy- 
sician to, and Physician to the department for Diseases of the Skin at, the 
Middlesex Hospital, London. Photo-lithochromes from the famous models 
of dermatological and syphilitic cases in the Museum of the Saint-Louis 
Hospital, Paris, with explanatory wood-cuts and letter-press. In 12 Parts, 
at $3.00 per Part. 

" Of all the atlases of skin diseases which have been published in recent years, the present 
one promises to be of greatest interest and value, especially from the standpoint of the 
general practitioner." — American Medico -Surgical Bulletin, Feb. 22, 1896. 

"The introduction of explanatory wood-cuts in the text is a novel and most important 
feature which greatly furthers the easier understanding of the excellent plates, than which 
nothing, we venture to say, has been seen better in point of correctness, beauty, and general 
merit." — New York Medical Journal, Feb. 15, 1896. 

" An interesting feature of the Atlas is the descriptive text, which is written for each picture 
by the physician who treated the case or at whose instigation the models have been made. 
We predict for this truly beautiful work a large circulation in all parts of the medical world 
where the names St. Louis and Baretta have preceded it." — Medical Record, N. Y., Feb. 1, 
1896. 

A TEXT-BOOK OF MECHANO-THERAPY (MASSAGE AND 
MEDICAL GYMNASTICS). By Axel V. Grafstrom, B. Sc, 
M. D., late Lieutenant in the Royal Swedish Army; late House Physi- 
cian, City Hospital, Blackwell's Island, New York. i2mo, 139 pages, 
illustrated. Cloth, $ 1. 00 net. 



CATALOGUE OF MEDICAL WORKS. 2$ 

DISEASES OF THE EYE. A Hand-Book of Ophthalmic Prac- 
tice. By G. E. DE Schweinitz, M. D., Professor of Ophthalmology in 
the Jefferson Medical College, Philadelphia, etc. A handsome royal- 
octavo volume of 696 pages, with 255 fine illustrations, many of which are 
original, and 2 chromo-lithographic plates. Prices : Cloth, $4.00 net ; 
Sheep or Half-Morocco, $5.00 net. 

THIRD EDITION, THOROUGHLY REVISED. 

In the third edition of this text-book, destined, it is hoped, to meet the favor- 
able reception which has been accorded to its predecessors, the work has been 
revised thoroughly, and much new matter has been introduced. Particular 
attention has been given to the important relations which micro-organisms bear 
to many ocular diseases. A number of special paragraphs on new subjects have 
been introduced, and certain articles, including a portion of the chapter on 
Operations, have been largely rewritten, or at least materially changed. A 
number of new illustrations have been added. The Appendix contains a full 
description of the method of determining the corneal astigmatism with the 
ophthalmometer of Javal and Schiotz, and the rotation of the eyes with the 
tropometer of Stevens. 

"A work that will meet the requirements not only of the specialist, but of the general 
practitioner in a rare degree. I am satisfied that unusual success awaits it." 

William Pepper, M. D. 

Provost and Professor of Theory and Practice of Medicine and Clinical Medicine 

in the University of Pennsylvania. 

"A clearly written, comprehensive manual. . . . One which we can commend to students 
as a reliable text-book, written with an evident knowledge of the wants of those entering upon 
the study of this special branch of medical science." — British Medical Journal . 

" It is hardly too much to say that for the student and practitioner beginning the study of 
Ophthalmology, it is the best single volume at present published." — Medical News. 

"It is a very useful, satisfactory, and safe guide for the student and the practitioner, and 
one of the best works of this scope in the English language." — Annals of Ophthalmology. 

DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant 
Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, London ; 
and Arthur E. Giles, M. D., B. Sc, Lond., F. R.C. S., Edin., Assistant 
Surgeon to Chelsea Hospital, London. 436 pages, handsomely illustrated. 
Cloth, $2.50 net. 

The authors have placed in the hands of the physician and student a concise 
yet comprehensive guide to tke study of gynecology in its most modern develop- 
ment. It has been their aim to relate facts and describe methods belonging to 
the science and art of gynecology in a way that will prove useful to students for 
examination purposes, and which will also enable the general physician to prac- 
tice this important department of surgery with advantage to his patients and with 
satisfaction to himself. 

" The book is very well prepared, and is certain to be well received by the medical public." 
— British Medical Journal. 

"The text has been carefully prepared. Nothing essential has been omitted, and its 
teachings are those recommended by the leading authorities of the day." — Journal of the 
American Medical Association. 



26 W. B. SAUNDERS' 



TEXT-BOOK UPON THE PATHOGENIC BACTERIA. Spe- 
cially written for Students of Medicine. By Joseph McFarland, 
M. D., Professor of Pathology and Bacteriology in the Medico-Chirurgical 
College of Philadelphia, etc. 497 pages, finely illustrated. Price, Cloth, 
$2.50 net. 

SECOND EDITION, REVISED AND GREATLY ENLARGED. 
The work is intended to be a text-book for the medical student and for the 
practitioner who has had no recent laboratory training in this department of medi- 
cal science. The instructions given as to needed apparatus, cultures, stainings, 
microscopic examinations, etc. are ample for the student's needs, and will afford 
to the physician much information that will interest and profit him relative to a 
subject which modern science shows to go far in explaining the etiology of many 
diseased conditions. 

In this second edition the work has been brought up to date in all depart- 
ments of the subject, and numerous additions have been made to the technique 
in the endeavor to make the book fulfil the double purpose of a systematic work 
upon bacteria and a laboratory guide. 

" It is excellently adapted for the medical students and practitioners for whom it is avowedly 
written. . . . The descriptions given are accurate and readable, and the book should prove 
useful to those for whom it is written. — London Lancet, Aug. 29, 1896. 

" The author has succeded admirably in presenting the essential details of bacteriological 
technics, together with a judiciously chosen summary of our present knowledge of pathogenic 
bacteria. . . . The work, we think, should have a wide circulation among English-speaking 
students of medicine." — N. Y. Medical Journal, April 4, 1896. 

" The book will be found of considerable use by medical men who have not had a special 
bacteriological training, and who desire to understand this important branch of medical 
science." — Edinburgh Medical Journal, July, 1896. 

LABORATORY GUIDE FOR THE BACTERIOLOGIST. By 

Langdon Frothingham, M. D. V., Assistant in Bacteriology and Veteri- 
nary Science, Sheffield Scientific School, Yale University. Illustrated. 
Price, Cloth, 75 cents. 

The technical methods involved in bacteria-culture, methods of staining, and 
microscopical study are fully described and arranged as simply and concisely as 
possible. The book is especially intended for use in laboratory work 

" It is a convenient and useful little work, and will more than repay the outlay necessary 
for its purchase in the saving of time which would otherwise be consumed in looking up the 
various points of technique so clearly and concisely laid down in its pages." — American Med.- 
Surg. Bulletin. 

FEEDING IN EARLY INFANCY. By Arthur V. Meigs, M. D. 
Bound in limp cloth, flush edges. Price, 25 cents net. 

Synopsis : Analyses of Milk — Importance of the Subject of Feeding in Early 
Infancy — Proportion of Casein and Sugar in Human Milk — Time to Begin Arti- 
ficial Feeding of Infants — Amount of Food to be Administered at Each Feed- 
ing — Intervals between Feedings — Increase in Amount of Food at Different 
Periods of Infant Development — Unsuitableness of Condensed Milk as a Sub- 
stitute for Mother's Milk — Objections to Sterilization or "Pasteurization" of 
Milk — Advances made in the Method of Artificial Feeding of Infants. 



CATALOGUE OF MEDICAL WORKS. 2J 

MATERIA MEDICA FOR NURSES. By Emily A. M, Stoney, 

Graduate of the Training-school for Nurses, Lawrence, Mass. ; late 
Superintendent of the Training-school for Nurses, Carney Hospital, South 
Boston, Mass. Handsome octavo, 300 pages. Cloth, $1.50 net. 

The present book differs from other similar works in several features, all of 
which are introduced to render it more practical and generally useful. The 
general plan of contents follows the lines laid down in training-schools for 
nurses, but the book contains much useful matter not usually included in works 
of this character, such as Poison-emergencies, Ready Dose-list, Weights and 
Measures, etc., as well as a Glossary, defining all the terms in Materia Medica, 
and describing all the latest drugs and remedies, which have been generally 
neglected by other books of the kind. 

ESSENTIALS OF ANATOMY AND MANUAL OF PRACTI- 
CAL DISSECTION, containing " Hints on Dissection. v By Chari.es 
B. Nancrede, M. D., Professor of Surgery and Clinical Surgery in the 
University of Michigan, Ann Arbor; Corresponding Member of the Royal 
Academy of M edicine, Rome, Italy ; late Surgeon Jefferson Medical Col- 
lege, etc. Fourth and revised edition, lost 8vo, over 500 pages, with 
handsome full-page lithographic plates in colors, and over 200 illustrations. 
Price : Extra Cloth or Oilcloth for the dissection-room, $2.00 net. 

Neither pains nor expense has been spared to make this work the most ex- 
haustive yet concise Student's Manual of Anatomy and Dissection ever pub- 
lished, either in America or in Europe. 

The colored plates are designed to aid the student in dissecting the muscles 
arteries, veins, and nerves. The wood-cuts have all been specially drawn and 
engraved, and an Appendix added containing 60 illustrations representing the 
structure of the entire human skeleton, the whole being based on the eleventh 
edition of Gray's Anatomy. 

A MANUAL OF PRACTICE OF MEDICINE. By A. A. Stevens, 
A. M., M. D., Instructor in Physical Diagnosis in the University of Penn- 
sylvania, and Professor of Pathology in the Woman's Medical College of 
Pennsylvania. Specially intended for students preparing for graduation 
and hospital examinations. Post* 8 vo, 519 pages. Numerous illustrations 
and selected formulae. Price, bound in flexible leather, $2. 00. net. 

FIFTH EDITION, REVISED AND ENLARGED. 

Contributions to the science of medicine have poured in so rapidly during the 
last quarter of a century that it is well-nigh impossible for the student, with the 
limited time at his disposal, to master elaborate treatises or to cull from them 
that knowledge which is absolutely essential. From an extended experience in 
teaching, the author has been enabled, by classification, to group allied symp- 
toms, and by the judicious elimination of theories and redundant explanations 
to bring within a comparatively small compass a complete outline of the prac- 
tice of medicine. 



28 W. B. SAUNDERS 



MANUAL OF MATERIA MEDICA AND THERAPEUTICS. 

By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the 
University of Pennsylvania, and Professor of Pathology in the Woman's 
Medical College of Pennsylvania. 445 pages. Price, bound in flexible 
leather, $2.25. 

SECOND EDITION, REVISED. 

This wholly new volume, which is based on the last edition of the Pharma- 
copoeia, comprehends the following sections: Physiological Action of Drugs; 
Drugs; Remedial Measures other than Drugs; Applied Therapeutics ; Incom- 
patibility in Prescriptions ; Table of Doses ; Index of Drugs ; and Index of 
Diseases; the treatment being elucidated by more than two hundred formulae. 

" The author is to be congratulated upon having presented the medical student with as 
accurate a manual of therapeutics as it is possible to prepare."— Therapeutic Gazette. 

" Far superior to most of its class ; in fact, it is very good. Moreover, the book is reliable 
and accurate." — New York Medical Journal. 

" The author has faithfully presented modern therapeutics in a comprehensive work, . , . 
and it will be found a reliable guide."— University Medical Magazine. 

NOTES ON THE NEWER REMEDIES: their Therapeutic Ap- 
plications and Modes of Administration. By David Cerna, M. D., 
Ph. D., Demonstrator of and Lecturer on Experimental Therapeutics in 
the University of Pennsylvania. Post-octavo, 253 pages. Price, #1.25. 

SECOND EDITION, RE-WRITTEN AND GREATLY ENLARGED. 

The work takes up in alphabetical order all the newer remedies, giving their 
physical properties, solubility, therapeutic applications, administration, and 
chemical formula. 

It thus forms a very valuable addition to the various works on therapeutics 
now in existence. 

Chemists are so multiplying compounds, that, if each compound is to be thor- 
oughly studied, investigations must be carried far enough to determine the prac- 
tical importance of the new agents. 

" Especially valuable because of its completeness, its accuracy, its systematic consider- 
ation of the properties and therapy of many remedies of which doctors generally know but 
little, expressed in a brief yet terse manner." — Chicago Clinical Review. 



TEMPERATURE CHART. Prepared by D. T. Laine, M. D. Size 
8x i^Yz inches. Price, per pad of 25 charts, 50 cents. 

A conveniently arranged chart for recording Temperature, with columns for 
daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the 
back of each chart is given in full the method of Brand in the treatment of 
Typhoid Fever. 



CATALOGUE OF MEDICAL WORKS. 2g 

A TEXT-BOOK OF HISTOLOGY, DESCRIPTIVE AND PRAC- 
TICAL. For the Use of Students. By Arthur Clarkson, M. B., 
C. M., Edin., formerly Demonstrator of Physiology in the Owen's College, 
Manchester; late Demonstrator of Physiology in the Yorkshire College, 
Leeds. Large Svo, 554 pages, with 22 engravings in the text, and 174 
beautifully colored original illustrations. Price, strongly bound in Cloth, 
$6.00 net. 

The purpose of the writer in this work has been to furnish the student of His- 
tology, in one volume, with both the descriptive and the practical part of the 
science. The first two chapters are devoted to the consideration of the general 
methods of Histology ; subsequently, in each chapter, the structure of the tissue 
or organ is first systematically described, the student is then taken tutorially over 
the specimens illustrating it, and, finally, an appendix affords a short note of the 
methods of preparation. 

" The work must be considered a valuable addition to the list of available text-books, and 
is to be highly recommended." — New York Medical Journal. 

" One of the best works for students we have ever noticed. We predict that the book will 
attain a well-deserved popularity among our students." — Chicago Medical Recorder. 



THE PATHOLOGY AND TREATMENT OF SEXUAL IM- 
POTENCE. By Victor G. Vecki, M. D. From the second Ger- 
man edition, revised and rewritten. Demi-octavo, about 300 pages. 
Cloth, $2.00 net. 

The subject of impotence has but seldom been treated in this country in the 
truly scientific spirit that it deserves, and this volume will come to many as a 
revelation of the possibilities of therapeusis in this important field. Dr. Vecki's 
work has long been favorably known, and the German book has received the 
highest consideration. This edition is more than a mere translation, for, although 
based on the German edition, it has been entirely rewritten by the author in 
English. 

" The work can be recommended as a scholarly treatise on its subject, and it can be read 
with advantage by many practitioners." — Journal of the American Medical Association. 

ARCHIVES OF CLINICAL SKIAGRAPHY. By Sydney Rowland, 
B. A., Camb. A series of collotype illustrations, with descriptive text, 
illustrating the applications of the New Photography to Medicine and Sur- 
gery. Price, per Part, $1.00. Parts I. to V. now ready. 

The object of this publication is to put on record in permanent form some of 
the most striking applications of the new photography to the needs of Medicine 
and Surgery. 

The progress of this new art has been so rapid that, although Prof. Rontgen's 
discovery is only a thing of yesterday, it has already taken its place among the 
approved and accepted aids to diagnosis. 



30 W. B. SAUNDERS' 



DISEASES OF WOMEN. By Henry J. Garrigues, A.M., M. D., 
Professor of Gynecology in the New York School of Clinical Medicine; 
Gynecologist to St. Mark's Hospital and to the German Dispensary, New 
York City. In one handsome octavo volume of 728 pages, illustrated by 
335 engravings and colored plates. Prices: Cloth, $4.00 net; Sheep or 
Half-Morocco, $5.00 net. 

A practical work on gynecology for the use of students and practitioners, 
written' in a terse and concise manner. The importance of a thorough know- 
ledge of the anatomy of the female pelvic organs has been fully recognized by 
the author, and considerable space has been devoted to the subject. The chap- 
ters on Operations and on Treatment are thoroughly modern, and are based 
upon the large hospital and private practice of the author. The text is eluci- 
dated by a large number of illustrations and colored plates, many of them being 
original, and forming a complete atlas for studying embryology and the anatomy 
of the female genitalia, besides exemplifying, whenever needed, morbid condi- 
tions, instruments, apparatus, and operations. 

Second Edition, Thoroughly Revised. 

The first edition of this work met with a most appreciative reception by the 
medical press and profession both in this country and abroad, and was adopted 
as a text-book or recommended as a book of reference by nearly one hundred 
colleges in the United States and Canada. The author has availed himself of 
the opportunity afforded by this revision to embody the latest approved advances 
in the treatment employed in this important branch of Medicine. He has also 
more extensively expressed his own opinion on the comparative value of the 
different methods of treatment employed. 

"One of the best text-books for students and practitioners which has been published in 
the English language; it is condensed, clear, and comprehensive. The profound learning 
and great clinical experience of the distinguished author find expression in this book in a 
most attractive and instructive form. Young practitioners, to whom experienced consultants 
may not be available, will find in this book invaluable counsel and help." 

Thad. A. Reamy, M. D., LL.D., 

Professor of Clinical Gynecology , Medical College of Ohio ; Gynecologist to the Good 

Samaritan and Cincinnati Hospitals. 



A SYLLABUS OF GYNECOLOGY, arranged in conformity with 
"An American Text-Book of Gynecology." By J. W. Long, M. D., 
Professor of Diseases of Women and Children, Medical College of Vir- 
ginia, etc. Price, Cloth (interleaved), $1.00 net. 

Based upon the teaching and methods laid down in the larger work, this will 
not only be useful as a supplementary volume, but to those who do not already 
possess the/text-book it will also have an independent value as an aid to the 
practitioner in gynecological work, and to the student as a guide in the lecture- 
room, as the subject is presented in a manner at once systematic, clear, succinct, 
?nd practical. 



CATALOGUE OF MEDICAL WORKS. 3 1 

THE AMERICAN POCKET MEDICAL DICTIONARY. Edited 
by W. A. Newman Dorland, M. D., Assistant Obstetrician to the Hospital 
of the University of Pennsylvania ; Fellow of the American Academy of 
Medicine. Containing the pronunciation and definition of over 26,000 
words used in medicine and the kindred sciences, with 64 extensive tables. 
Handsomely bound in flexible leather, limp, with gold edges and patent 
thumb index. Price, $1.25 net. 

SECOND EDITION, REVISED. 

Over 26,000 Words, 64 Valuable Tables. 

This is the ideal pocket lexicon. It is an absolutely new book, and not a re- 
vision of any old work. It is complete, defining all the terms of modern medi- 
cine and forming a vocabulary of over 26,000 words. It gives the pronunciation 
of all the terms. It makes a special feature of the newer words neglected by 
other dictionaries. It contains a wealth of anatomical tables of special value to 
students. It forms a handy volume, indispensable to every medical man. 

SAUNDERS' POCKET MEDICAL FORMULARY. By William 
M. Powell, M. D., Attending Physician to the Mercer House for Invalid 
Women at Atlantic City. Containing 1800 Formulae, selected from several 
hundred of the best-known authorities. Forming a handsome and con- 
venient pocket companion of nearly 300 printed pages, with blank leaves 
for x\dditions; with an Appendix containing Posological Table, Formulae 
and Doses for Hypodermatic Medication, Poisons and their Antidotes, 
Diameters of the Pemale Pelvis and Fcetal Head, Obstetrical Table, Diet 
List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, 
Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables 
of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- 
somely bound in morocco, with side index, wallet, and flap. Price, $1.75 
net. 

FIFTH EDITION, THOROUGHLY REVISED. 

"This little book, that can be conveniently carried in the pocket, contains an immense 
amount of material. It is very useful, and as the name of the author of each prescription is 
given, is unusually reliable." — Neiv York Medical Record. 

A COMPENDIUM OF INSANITY. By John B. Chapin, M.D., LL .1)., 
Physician-in-Chief, Pennsylvania Hospital for the Insane; late Physician- 
Superintendent of'the Willard State Hospital, New York; Honorary Mem- 
ber of the Medico-Psychological Society of Great Britain, of the Society of 
Mental Medicine of Belgium. 121110, 234 pages, illust. Cloth, $1.25 net. 

The author has given, in a condensed and concise form, a compendium of 
Diseases of the Mind, for the convenient use and aid of physicians and students. 
It contains a clear, concise statement of the clinical aspects of the various ab- 
normal mental conditions, with directions as to the most approved methods of 
managing and treating the insane. 

" The practical parts of Dr. Chapin's book are what constitute its distinctive merit. We 
desire especially, however, to call attention to the fact that in the subject of the therapeutics 
of insanity the work is exceedingly valuable. The author has made a distinct addition to the 
literature of his specialty." — PhiladelpJiia Medical Journal. 



32 W. B. SAUNDERS' 



AN OPERATION BLANK, with Lists of Instruments, etc. re- 
quired in Various Operations. Prepared by W. W. Keen, M. D., 
LL.D., Professor of Principles of Surgery in the Jefferson Medical Col- 
lege, Philadelphia. Price per Pad, containing Blanks for fifty operations, 
50 cents net. 

SECOND EDITION, REVISED FORM. 

A convenient blank, suitable for all operations, giving complete instructions 
regarding necessary preparation of patient, etc., with a full list of dressings and 
medicines to be employed. 

On the back of each blank is a list of instruments used — viz. general instru 
ments, etc., required for all operations ; and special instruments for surgery of 
the brain and spine, mouth and throat, abdomen, rectum, male and female 
genito-urinary organs, the bones, etc. 

The whole forming a neat pad, arranged for hanging on the wall of a sur- 
geon's office or in the hospital operating-room. 

" Will serve a useful purpose for the surgeon in reminding him of the details of prepa- 
ration for the patient and the room as well as for the instruments, dressings, and antiseptics 
needed." — New York Medical Record 

" Covers about all that can be needed in any operation." — American Lancet, 

" The plan is a capital one." — Boston Medical and Surgical Journal. 

LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin, 
M. A., Professor of Materia Medica and Botany in the Philadelphia Col- 
lege of Pharmacy. Octavo volume of 536 pages, 87 full-page plates. Price, 
Cloth, $2.50. 

This work is intended for the beginner and the advanced student, and it fully 
covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers, 
bulbs, leaves, flowers, fruits, and seeds. Particular attention is given to the gross 
and microscopical structure of plants, and to those used in medicine. Illustra- 
tions have freely been used to elucidate the text, and a complete index to facil- 
itate reference has been added. 

" There is no work like it in the pharmaceutical or botanical literature of this country, and 
we predict for it a wide circulation." — American Journal of Pharmacy. 

DIET IN SICKNESS AND IN HEALTH. By Mrs. Ernest Hart, 
formerly Student of the Faculty of Medicine of Paris and of the London 
School of Medicine for Women; with an Introduction by Sir Henry 
Thompson, F. R. C. S., M. D., London. 220 pages; illustrated. Price, 
Cloth, #1.50. 

Useful to those who have to nurse, feed, and prescribe for the sick. In 
each case the accepted causation of the disease and the reasons for the special 
diet prescribed are briefly described. Medical men will find the dietaries and 
recipes practically useful, and likely to save them trouble in directing the dietetic 
treatment of patients. 



CATALOGUE OF MEDICAL WORKS. 33 

/ MANUAL OF PHYSIOLOGY, with Practical Exercises. For 
Students and Practitioners. By G.'N. Stewart, M. A., M. D., D. Sc, 
lately Examiner in Physiology, University of Aberdeen, and of the New 
Museums, Cambridge University ; Professor of Physiology in the Western 
Reserve University, Cleveland, Ohio. Handsome octavo volume of 848 
pages, with 300 illustrations in the text, and 5 colored plates. Price, Cloth, 

$3-75 net - 

THIRD EDITION, REVISED. 

" It will make its way by sheer force of merit, and amply deserves to do so. It is one oj 
the very best English text-books on the subject." — London Lancet. 

M Of the many text-books of physiology published, we do not know of one that so nearly 
comes up to the ideal as does Professor Stewart's volume." — British Medical Journal. 

ESSENTIALS OF PHYSICAL DIAGNOSIS OF THE THORAX. 

By Arthur M. Corwin, A. M., M. D., Demonstrator of Physical Diagno- 
sis in the Rush Medical College, Chicago; Attending Physician to the 
Central Free Dispensary, Department of Rhinology, Laryngology, and 
Diseases of the Chest. 200 pages. Illustrated. Cloth, flexible covers. 
Price. $1.25 net. 

SECOND EDITION, THOROUGHLY REVISED AND ENLARGED. 

SYLLABUS OF OBSTETRICAL LECTURES in the Medical 
Department, University of Pennsylvania. By Richard C. Norris, 
A. M., M. D., Lecturer on Clinical and Operative Obstetrics, University 
of Pennsylvania. Third edition, thoroughly revised and enlarged. Crown 
8vo. Price, Cloth, interleaved for notes, $2.00 net. 

• " This work is so far superior to others on the same subject that we take pleasure in call- 
ing attention briefly to its excellent features. It covers the subject thoroughly, and will 
prove invaluable both to the student and the practitioner. The author has introduced a 
number of valuable hints which would only occur to one who was himself an experienced 
teacher of obstetrics. The subject-matter is clear, forcible, and modern. We are especially 
pleased with the portion devoted to the practical duties of the accoucheur, care of the child, 
etc. The paragraphs on antiseptics are admirable; there is no doubtful tone in the direc- 
tions given. No details are regarded as unimportant ; no minor matters omitted. We ven- 
ture to say that even the old practitioner will find useful hints in this direction which he can- 
not afford to despise." — Neiv York Medical Record. 

A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR- 
GERY, arranged in conformity with " An American Text-Book 
of Surgery." By N. Senn, M. D., Ph. D., Professor of Surgery in Rusl 
Medical College, Chicago, and in the Chicago Polyclinic. Price, $2.00. 

This work by so eminent an author, himself one of the contributors to 
" An American Text-Book of Surgery," will prove of exceptional value to 
the advanced student who has adopted that work as his text-book. It is not 
only the syllabus of an unrivalled course of surgical practice, but it is also an 
epitome of or supplement to the larger work. 

" The author has evidently spared no pains in making his Syllabus thoroughly comprehen- 
sive, and har, added new matter and alluded to the most recent authors and operations. Full 
references are also given to all requisite details of surgical anatomy and pathology." — British 
Medical Journal ', London. 



34 TV. B. SAUNDERS' 



THE CARE OF THE BABY. By J. P. Crozer Griffith, M. D., 
Clinical Professor of Diseases of Children, University of Pennsylvania; 
Physician to the Children's Hospital, Philadelphia, etc. 404 pages, with 
67 illustrations in the text, and 5 plates. i2mo. Price, $1.50. 

SECOND EDITION, REVISED. 

A reliable guide not only for mothers, but also for medical students and 
practitioners whose opportunities for observing children have been limited. 

" The whole book is characterized by rare good sense, and is evidently written by a mas. 
ter hand. It can be read with benefit not only by mothers, but by medical students and by 
any practitioners who have not had large opportunities for observing children."— A merican 
youmal of Obstetrics. 

THE NURSE'S DICTIONARY of Medical Terms and Nursing 
Treatment, containing Definitions of the Principal Medical and Nursing 
Terms, Abbreviations, and Physiological Names, and Descriptions of the 
Instruments, Drugs, Diseases, Accidents, Treatments, Operations, Foods, 
Appliances, etc. encountered in the ward or the sick-room. By Honnor 
Morten, author of "How to Become a Nurse," "Sketches of Hospital 
Life," etc. i6mo, 140 pages. Price, Cloth, $1.00. 

This little volume is intended for use merely as a small reference-book which 
can be consulted at the bedside or in the ward. It gives sufficient explanation 
to the nurse to enable her to comprehend a case until she has leisure to look up 
larger and fuller works on the subject. 

DIET LISTS AND SICK-ROOM DIETARY. By Jerome B. Thomas, 
M. D., Visiting Physician to the Home for Friendless Women and Children 
and to the Newsboys' Home ; Assistant Visiting Physician to the Kings 
County Hospital; Assistant Bacteriologist, Brooklyn Health Department. 
Price, Cloth, $1.50 (Send for specimen List.) 

One hundred and sixty detachable (perforated) diet lists for Albuminuria, 
Anaemia and Debility, Constipation, Diabetes, Diarrhoea, Dyspepsia, Fevers, 
Gout or Uric- Acid Diathesis, Obesity, and Tuberculosis. Also forty detachable 
sheets of Sick-Room Dietary, containing full instructions for preparation of 
easily-digested foods necessary for invalids. Each list is numbered only, the 
disease for which it is to be used in no case being mentioned, an index key 
being reserved for the physician's private use. 

DIETS FOR INFANTS AND CHILDREN IN HEALTH AND 
IN DISEASE. By Louis Starr, M. D., Editor of " An American 
Text-Book of the Diseases of Children." 230 blanks (pocket-book size), 
perforated and neatly bound in flexible morocco. Price, J 1.25 net. 

The first series of blanks are prepared for the first seven months of infant 
life ; each blank indicates the ingredients, but not the quantities, of the food, 
the latter directions being left for the physician. After the seventh month, 
modifications being less necessary, the diet lists are printed in full. Formula 
foi trie preparation of diluents and foods are appended. 



CATALOGUE OF MEDICAL WORKS. 35 



HOW TO EXAMINE FOR LIFE INSURANCE. By Jo*N M. 
Keating, M. D., Fellow of the College of Physicians and Surgeons of 
Philadelphia; Vice-President of the American Pediatric Society; Ex- 
President of the Association of Life Insurance Medical Directors. Royal 
8vo, 211 pages, with two large half-tone illustrations, and a plate prepared 
by Dr. McClellan from special dissections ; also, numerous cuts to elucidate 
the text. Third edition. Price, Cloth, $2.00 net. 

" This is by far the most useful book which has yet appeared on insurance examination, a 
subject of growing interest and importance. Not the least valuable portion of the volume is 
Part II., which consists of instructions issued to their examining physicians by twenty-four 
representative companies of this country. As the proofs of these instructions were corrected 
by the directors of the companies, they form the latest instructions obtainable. If for these 
alone, the book should be at the right hand of every physician interested in this special branch 
of medical science." — The Medical News, Philadelphia. 

NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel 
Adams Hampton, Graduate of the New York Training School for 
Nurses attached to Bellevue Hospital; Superintendent of Nurses and 
Principal of the Training School for Nurses, Johns Hopkins Hospital, 
Baltimore, Md. ; late Superintendent of Nurses, Illinois Training School 
for Nurses, Chicago, 111. In one very handsome i2mo volume of 512 
pages, illustrated. Price, Cloth, $2.00 net. 

SECOND EDITION, REVISED AND ENLARGED. 

This original work on the important subject of nursing is at once comprehensive 
and systematic. It is written in a clear, accurate, and readable style, suitable 
alike to the student and the lay reader. Such a work has long been a desidera- 
tum with those entrusted with the management of hospitals and the instruction of 
nurses in training-schools. It is also of especial value to the graduated nurse 
who desires to acquire a practical working knowledge of the care of the sick 
and the hygiene of the sick-room. 

OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERA- 
TIONS. By L. Ch. Boisijniere, M. D., late Emeritus Professor of 
Obstetrics in the St. Louis Medical College. 381 pages, handsomely illus- 
trated. Price, $2.00 net. 

" For the use of the practitioner who, when away from home, has not the 
opportunity of consulting a library or of calling a friend in consultation. He 
then, being thrown upon his own resources, will find this book of benefit in 
guiding and assisting him in emergencies." 

INFANT'S WEIGHT CHART. Designed by J. P. Crozer Grjffith, 
M. D., Clinical Professor of Diseases of Children in the University of Peni\ 
sylvania. 25 charts in each pad. Price per pad, 50 cents net. 

A convenient blank for keeping a record of the child's weight during the first 
two years of life. Printed on each chart is a curve representing the average weight 
of a healthy infant, so that any deviation from the normal can readily be detected 




saunders' 
New Series 
of Manuals 



for Students 
and 
Practitioners* 



THAT there exists a need for thoroughly reliable hand-books on the leading 
branches of Medicine and Surgery is a fact amply demonstrated by the 
favor with which the SAUNDERS NEW SERIES OF MANUALS have been 
received by medical students and practitioners and by the Medical Press. 
These manuals are not merely condensations from present literature, but 
are ably written by well-known authors and practitioners, most of them being 
teachers in representative American colleges. Each volume is concisely and 
authoritatively written and exhaustive in detail, without being encumbered 
with the introduction of "cases," which so largely expand the ordinary text- 
book. These manuals will therefore form an admirable collection of advanced 
lectures, useful alike to the medical student and the practitioner: to the latter, 
too busy to search through page after page of elaborate treatises for what he 
wants to know, they will prove of inestimable value ; to the former they will 
afford safe guides to the essential points of study. 

The SAUNDERS NEW SERIES OF MANUALS are conceded to be 
superior to any similar books now on the market. No other manuals afford so 
much information in such a concise and available form. A liberal expenditure 
has enabled the publisher to render the mechanical portion of the work worthy 
of the high literary standard attained by these books. 

Any of these Manuals will be mailed on receipt of price (see next page 
*or List). 



SAUNDERS' NEW SERIES OF MANUALS, 



VOLUMES PUBLISHED. 



PHYSIOLOGY. By Joseph Howard Raymond, A. M., M. D., Professor 
of Physiology and Hygiene and Lecturer on Gynecology in the Long 
Island College Hospital, etc. Price, $1.25 net. 

SURGERY, General and Operative. By John Chalmers DaCosta, 

M. D., Professor of Clinical Surgery, Jefferson Medical College, Philadel- 
phia. Second edition, revised and greatly enlarged. Octavo, 911 pages, 
386 illustrations. Cloth, $4.00 net ; Half- Morocco, $5.00 net. 

DOSE-BOOK AND MANUAL OF PRESCRIPTION- WRITING. 

By E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson 
Medical College, Philadelphia. Price, $1.25 net. 

MEDICAL JURISPRUDENCE. By Henry C. Chapman, M. D., Pro- 
fessor of Institutes of Medicine and Medical Jurisprudence in the Jeffer- 
son Medical College of Philadelphia, etc, Price, $1.50 net. 

SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's 
Hospital and to the German Poliklinik ; Instructor in Surgery, New York 
Post-Graduate Medical School, etc. Price, $1.25 net. 

MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct 
Professor of Anatomy and Demonstrator of Anatomy, Medical Department 
of the New York University, etc. Price, $2. 50 net. 

SYPHILIS AND THE VENEREAL DISEASES. By James 
Nevins Hyde, M. D., Professor of Skin and Venereal Diseases, and 
Frank H. Montgomery, M. D., Lecturer on Dermatology and Genito- 
urinary Diseases in Rush Medical College, Chicago. Price, $2.50 net. 

PRACTICE OF MEDICINE. By George Roe Lockwood, M. D., 
Professor of Practice in the Woman's Medical College of the New York 
Infirmary, etc. Price, $2.50 net. 

OBSTETRICS. By W. A. Newman Dorland, M. D., Assistant Demon- 
strator of Obstetrics, University of Pennsylvania; Chief of Gynecological 
Dispensary, Pennsylvania Hospital. Price, $2.50 net. 

DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant 

Surgeon to the Middlesex Hospital, and Surgeon to the Chelsea Hospital 
for" Women, London ; and Arthur E. Giles, M. D., B. Sc. Lond., F. R. C. S. 
Edin., Assistant Surgeon to the Chelsea Hospital for Women, London. 436 
pages, handsomely illustrated. Price, $2.50 net. 

IN PREPARATION. 

NERVOUS DISEASES. By Charles W. Burr, M. D., Clinical Profes- 
sor of Nervous Diseases, Medico-Chirurgical College, Philadelphia, etc. 

*** There will be published in the same series, at short intervals, carefully prepared works 
on various subjects, by prominent specialists. 

37 



SAUNDERS' QUESTION COMPENDS. 

Arranged in Question and Answer Form, 

THE LATEST, MOST COMPLETE, and BEST ILLUSTRATED 
SEEIES OF COMPENDS EVER ISSUED. 



Now the Standard Authorities in Medical Literature 



WITH 



Students and Practitioners in every City of the United 

States and Canada. 



THE REASON WHY. 

They are the advance guard of " Student's Helps " — that DO HELP; they are 
the leaders in their special line, well and authoritatively written by able men, 
who, as teachers in the large colleges, know exactly what is wanted by a student 
preparing for his examinations. The judgment exercised in the selection of 
authors is fully demonstrated by their professional elevation. Chosen from the 
ranks of Demonstrators, Quiz-masters, and Assistants, most of them have be- 
come Professors and Lecturers in their respective colleges. 

Each book is of convenient size (5x7 inches), containing on an average 250 
pages, profusely illustrated, and elegantly printed in clear, readable type, on 
fine paper. 

The entire series, numbering twenty- four subjects, has been kept thoroughly 
revised and enlarged when necessary, many of them being in their fourth and 
fifth editions. 

TO SUM UP. 

Although there are numerous other Quizzes, Manuals, Aids, etc. in the mar- 
ket, none of them approach the " Blue Series of Question Compends; 1 ' and 
the claim is made for the following points of excellence : 

1. Professional distinction and reputation of authors. 

2. Conciseness, clearness, and soundness of treatment. 

3. Size of type and quality of paper and binding. 

*#* Any of these Compends will be mailed on receipt of price (see next 

page for List). 

38 



SAUNDERS' QUESTION-COMPEND SERIES. 



Price, Cloth, $J*00 per copy, except when otherwise noted* 

1. ESSENTIALS OF PHYSIOLOGY. 4th edition. Illustrated. Revised and enlarged. 

By H. A. Hare, M. D. (Price, $1.00 net.) 

2. ESSENTIALS OF SURGERY. 6th edition, with an Appendix on Antiseptic Sur- 

gery. 90 illustrations. By Edward Martin, M. D. 

3. ESSENTIALS OF ANATOMY. 6th edition, thoroughly revised. 151 illustrations. 

By Charles B. Nancrede, M. D. 

4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGAJMIC, 

5th edition, revised, with an Appendix. By Lawrence Wolff, M. D. 

5. ESSENTIALS OF OBSTETRICS. 4th edition, revised and enlarged. 75 illustra- 

tions. By W. Easterly Ashton, M. D. 

6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. 7th thousand. 

46 illustrations. By C. E. Armand Semple, M. D. 

7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- 

SCRIPTION-WRITING. 5th edition. By Henry Morris, M. D. 

8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M.D. 

An Appendix on Urine Examin ation. Illustrated. By Lawrence Wolff, M. D. 
3d edition, enlarged by some 300 Essential Formulae, selected from eminent authori- 
ties, by Wm. ML Powell. M. D. (Double number, price $2.00.) 

10. ESSENTIALS OF GYNECOLOGY. 4th edition, revised. With 62 illustrations. 

By Edwin B. Cragin, M. D. 

11. ESSENTIALS OF DISEASES OF THE SKIN. 4th edition, revised and enlarged. 

71 letter-press cuts and 15 half-tone illustrations. By Henry W. Stelwagon, M.D. 
(Price, $1.00 net.) 

12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL 

DISEASES. 2d edition, revised and enlarged. 78 illustrations. By Edward 
Martin, M. D. 

13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 

130 illustrations. By C. E. Armand Semple, M. D. 

14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 124 

illustrations. 2d edition, revised. By Edward Jackson, M. D., and E. Baldwin 
Gleason, M. D. 

15. ESSENTIALS OF DISEASES OF CHILDREN. 2d edition. By William M 

Powell, M. D. 

16. ESSENTIALS OF EXAMINATION OF URINE. Colored " Vogel Scale," 

and numerous illustrations. By Lawrence Wolff, M.D. (Price, 75 cents.) 

17. ESSENTIALS OF DIAGNOSIS. 55 illustrations, some in colors. By S. Solis- 

Cohen, M. D., and A. A. Eshner, M. D. (Price, $1.50 net.) 

18. ESSENTIALS OF PRACTICE OF PHARMACY. 2d edition, revised. By L. 

E. Sayre. 

20. ESSENTIALS OF BACTERIOLOGY. 3d edition. 82 illustrations. By M. V. 

Ball, M.D. 

21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. 48 illustrations. 

3d edition, revised. By John C. Shaw, M. D. 

22. ESSENTIALS OF MEDICAL PHYSICS. 155 illustrations. 2d edition, revised. 

By Fred J. Brockway, M. D. (Price, $1.00 net.) 

23. ESSENTIALS OF MEDICAL ELECTRICITY. 65 illustrations. By David D. 

Stewart, M. D., and Edward S. Lawrance, M. D. 

24. ESSENTIALS OF DISEASES OF THE EAR. 114 illustrations. 2d edition, re- 

vised and enlarged. By E. Baldwin Gleason, M. D. 

39 



IN PRESS 

FOR PUBLICATION EARLY IN THE FALL OF J899. 



THE INTERNATIONAL TEXT-BOOK OF SURGERY. In two vols 
By American and British authors. Edited by J. Collins Warren, M. D. 
LL.D., Professor of Surgery, Harvard Medical School, Boston ; Surgeon 
to the Massachusetts General Hospital; and A. Pearce Gould, M. S., 
F. R. C. S., Eng., Lecturer on Practical Surgery and Teacher of Operative 
Surgery, Middlesex Hospital Medical School ; Surgeon to the Middlesex 
Hospital, London, England. Vol. I. Handsome octavo volume of about 
95° P a ges, with over 400 beautiful illustrations in the text, and 9 litho- 
graphic plates. 

HEISLER'S EMBRYOLOGY. 

A Text=Book of Embryology. By John C. Heisler, M. D., Pro- 
fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. i2mo 
volume of about 325 pages, handsomely illustrated. 

KYLE ON THE NOSE AND THROAT. 

Diseases of the Nose and Throat. By D. Braden Kyle, M. D., 
Clinical Professor of Laryngology and Rhinology, Jefferson Medical Col- 
lege, Philadelphia; Consulting Laryngologist, Rhinologist, and Otologist, 
St. Agnes' Hospital. Octavo volume of about 630 pages, with over 150 
illustrations and 6 lithographic plates. 

PRYOR PELVIC INFLAMMATIONS. 

The Treatment of Pelvic Inflammations through the Vagina. 

By W. R. Pryor, M. D., Professor of Gynecology in the New York Poly- 
clinic. i2mo volume of about 250 pages, handsomely illustrated. 

ABBOTT ON TRANSMISSIBLE DISEASES. 

The Hygiene of Transmissible Diseases: their Causation, 
Modes of Dissemination, and Methods of Prevention. By A. 

C. ABBOTT, M. D., Professor of Hygiene in the University of Pennsyl- 
vania ; Director of the Laboratory of Hygiene. Octavo volume of about 
325 pages, containing a number of charts and maps, and numerous illus- 
trations. 

JACKSON -DISEASES OF THE EYE. 

A Manual of Diseases of the Eye. By Edward Jackson, A. M., 
M. D., late Professor of Diseases of the Eye in the Philadelphia Polyclinic 
and College for Graduates in Medicine. I2mo volume of over 500 pages, 
with about 175 beautiful illustrations from drawings by the author. 







■£R£SL 0F CONGRESS 




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